Healthcare Provider Details

I. General information

NPI: 1609414754
Provider Name (Legal Business Name): JOHN PAUL KRETKOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FLEMINGTON DR
LAKE WACCAMAW NC
28450-1932
US

IV. Provider business mailing address

2007 RED WOODPECKERS CT
LELAND NC
28451-5654
US

V. Phone/Fax

Practice location:
  • Phone: 910-646-3083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22239
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number012200
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: