Healthcare Provider Details

I. General information

NPI: 1356913842
Provider Name (Legal Business Name): NORTH CAROLINA PSYCH SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3771 RAMSEY ST STE 109-140
FAYETTEVILLE NC
28311-7675
US

IV. Provider business mailing address

3593 MEDINA RD # 181
MEDINA OH
44256-8182
US

V. Phone/Fax

Practice location:
  • Phone: 330-536-3746
  • Fax: 330-267-4250
Mailing address:
  • Phone: 330-536-3746
  • Fax: 330-267-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROBERT RAE
Title or Position: CEO
Credential: MD
Phone: 330-536-3746