Healthcare Provider Details

I. General information

NPI: 1750136941
Provider Name (Legal Business Name): SIMPLY MIND OVER MATTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5540 CENTERVIEW DR STE 204
RALEIGH NC
27606-8012
US

IV. Provider business mailing address

6375 SWANNS STATION RD
SANFORD NC
27332-7796
US

V. Phone/Fax

Practice location:
  • Phone: 910-690-6648
  • Fax:
Mailing address:
  • Phone: 910-690-6648
  • 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 Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TABATHA A. TREAGER
Title or Position: BUSINESS OWNER/EMPLOYEE
Credential: LCSW
Phone: 910-690-6648