Healthcare Provider Details

I. General information

NPI: 1487376398
Provider Name (Legal Business Name): FLOURISH HEALTH MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST
DURHAM NC
27701-3228
US

IV. Provider business mailing address

201 W MAIN ST
DURHAM NC
27701-3228
US

V. Phone/Fax

Practice location:
  • Phone: 650-863-4774
  • Fax:
Mailing address:
  • Phone: 650-863-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN HASKELL
Title or Position: SECRETARY
Credential:
Phone: 650-863-4774