Healthcare Provider Details

I. General information

NPI: 1578293361
Provider Name (Legal Business Name): FORWARD MOMENTUM THERAPEUTIC SOLUTIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 W CHURCH ST
CREEDMOOR NC
27522-9747
US

IV. Provider business mailing address

2227 BAYSWATER DR
CREEDMOOR NC
27522-7837
US

V. Phone/Fax

Practice location:
  • Phone: 252-425-7527
  • Fax:
Mailing address:
  • Phone: 252-425-7527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ELAINA RASHID TERRY
Title or Position: OWNER
Credential: LCMHCS
Phone: 252-425-7527