Healthcare Provider Details

I. General information

NPI: 1437592771
Provider Name (Legal Business Name): NC RECOVERY SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W MILLBROOK RD SUITE 161
RALEIGH NC
27609-4385
US

IV. Provider business mailing address

309 W MILLBROOK RD SUITE 161
RALEIGH NC
27609-4385
US

V. Phone/Fax

Practice location:
  • Phone: 919-889-2663
  • Fax: 919-882-1277
Mailing address:
  • Phone: 919-889-2663
  • Fax: 919-882-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL GLENN
Title or Position: DIRECTOR
Credential:
Phone: 919-889-2663