Healthcare Provider Details

I. General information

NPI: 1306196944
Provider Name (Legal Business Name): MINDLY GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8406 SIX FORKS RD SUITE 204
RALEIGH NC
27615-3074
US

IV. Provider business mailing address

8406 SIX FORKS RD SUITE 204
RALEIGH NC
27615-3074
US

V. Phone/Fax

Practice location:
  • Phone: 919-617-9656
  • Fax: 919-617-9656
Mailing address:
  • Phone: 919-617-9656
  • Fax: 919-617-9656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8809
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC007721
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE DAWN PHILLIPS
Title or Position: OWNER
Credential: LCMHCS
Phone: 919-617-9656