Healthcare Provider Details

I. General information

NPI: 1578797536
Provider Name (Legal Business Name): WAKE COUNSELING ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2304 S MIAMI BLVD STE 223
DURHAM NC
27703-4915
US

IV. Provider business mailing address

PO BOX 1215
KNIGHTDALE NC
27545-1215
US

V. Phone/Fax

Practice location:
  • Phone: 191-920-0609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6803
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. BONNIE ANN FITTS
Title or Position: OWNER
Credential: MA, LPC
Phone: 19192006091