Healthcare Provider Details

I. General information

NPI: 1760039937
Provider Name (Legal Business Name): DIRECT REALISTIC COUNSELING SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 12/22/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 HIGHWAY 70 SUITE R
GARNER NC
27529
US

IV. Provider business mailing address

212 CRESTDALE DR
CLAYTON NC
27520-5515
US

V. Phone/Fax

Practice location:
  • Phone: 919-706-9448
  • Fax:
Mailing address:
  • Phone: 919-706-9448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. DAMEN RAHEEM CROMWELL SR.
Title or Position: OWNER
Credential: DR.
Phone: 919-332-9294