Healthcare Provider Details

I. General information

NPI: 1700468287
Provider Name (Legal Business Name): BRENDA EILEEN MULLIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2021
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 FORTUNES RIDGE DR STE P
DURHAM NC
27713-6102
US

IV. Provider business mailing address

5948 ROUNDER LN
HOLLY SPRINGS NC
27540-9683
US

V. Phone/Fax

Practice location:
  • Phone: 919-391-7202
  • Fax:
Mailing address:
  • Phone: 919-608-2905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC008561
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: