Healthcare Provider Details

I. General information

NPI: 1649694357
Provider Name (Legal Business Name): PROMINENCE CONSULTING & THERAPUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2014
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 WATERS EDGE DR 204
RALEIGH NC
27606-2462
US

IV. Provider business mailing address

4909 WATERS EDGE DR 204
RALEIGH NC
27606-2462
US

V. Phone/Fax

Practice location:
  • Phone: 919-841-8679
  • Fax:
Mailing address:
  • Phone: 919-841-8679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1577
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1577
License Number StateNC

VIII. Authorized Official

Name: COURTNEY STRICKLAND
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW, LCAS, LCSWA,
Phone: 919-841-8679