Healthcare Provider Details

I. General information

NPI: 1538366109
Provider Name (Legal Business Name): TRIUMPH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 03/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 FAIRHILL DR
RALEIGH NC
27612-3220
US

IV. Provider business mailing address

3210 FAIRHILL DR
RALEIGH NC
27612-3220
US

V. Phone/Fax

Practice location:
  • Phone: 919-256-0824
  • Fax:
Mailing address:
  • Phone: 919-256-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. PAUL CALDWELL
Title or Position: CEO
Credential:
Phone: 919-467-2433