Healthcare Provider Details

I. General information

NPI: 1497057319
Provider Name (Legal Business Name): STEPHEN EDWARD WOODS MDIV, LPC, LCAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

7925 PURFOY RD
FUQUAY VARINA NC
27526-8937
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-8395
  • Fax: 919-350-2995
Mailing address:
  • Phone: 919-557-5840
  • Fax: 919-557-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7992
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-20025
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: