Healthcare Provider Details

I. General information

NPI: 1730859513
Provider Name (Legal Business Name): SIMPLY TEEN OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W WILLIAMS ST STE 203
APEX NC
27502-5200
US

IV. Provider business mailing address

800 W WILLIAMS ST STE 203
APEX NC
27502-5200
US

V. Phone/Fax

Practice location:
  • Phone: 919-869-5301
  • Fax: 855-678-6632
Mailing address:
  • Phone: 919-869-5301
  • Fax: 855-678-6632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. TINA MARIE KINNAN
Title or Position: OWNER/THERAPIST
Credential: MRC, LCMHCS
Phone: 919-869-5301