Healthcare Provider Details

I. General information

NPI: 1134424542
Provider Name (Legal Business Name): OUR TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2011
Last Update Date: 07/11/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 WATERS EDGE DR 104
RALEIGH NC
27606-2462
US

IV. Provider business mailing address

1702 SHERIFF WATSON RD
SANFORD NC
27332-6720
US

V. Phone/Fax

Practice location:
  • Phone: 919-601-1313
  • Fax:
Mailing address:
  • Phone: 919-601-1313
  • Fax: 919-267-9079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7134
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TASHA HOLLAND-KORNEGAY
Title or Position: OWNER
Credential: PHD, LPC
Phone: 919-601-1313