Healthcare Provider Details

I. General information

NPI: 1760293674
Provider Name (Legal Business Name): CARLYE DENEQUOLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 FAYETTEVILLE RD # 202
DURHAM NC
27713-9661
US

IV. Provider business mailing address

600 DURANT ST APT 203
CHAPEL HILL NC
27517-7360
US

V. Phone/Fax

Practice location:
  • Phone: 919-748-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA20313
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: