MEDICARE: WAKE PSYCHOLOGICAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	2119	NC

General Provider Information

NPI Number	:	1760897094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	1612 BARONY LAKE WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-8478
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1612 BARONY LAKE WAY
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27614-8478
Country	:	US
Telephone Number	:	919-308-8470
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TIJUANA CROSBY
Credential	:
Telephone Number	:	919-308-8470

Provider Enumeration Date	:	06/25/2014
Last Update Date	:	06/25/2014

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