Healthcare Provider Details

I. General information

NPI: 1417390444
Provider Name (Legal Business Name): DURHAM DBT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 FAYETTEVILLE RD SUITE 201
DURHAM NC
27713-6289
US

IV. Provider business mailing address

5850 FAYETTEVILLE RD SUITE 201
DURHAM NC
27713-6289
US

V. Phone/Fax

Practice location:
  • Phone: 919-627-8675
  • Fax:
Mailing address:
  • Phone: 919-627-8675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMMY FAWZY BANAWAN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 919-627-8675