Healthcare Provider Details

I. General information

NPI: 1710164454
Provider Name (Legal Business Name): SOUTHEAST FAMILY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 NATIONAL DRIVE SUITE 124
RALEIGH NC
27612-4863
US

IV. Provider business mailing address

3716 NATIONAL DRIVE SUITE 124
RALEIGH NC
27612-4863
US

V. Phone/Fax

Practice location:
  • Phone: 919-783-8846
  • Fax:
Mailing address:
  • Phone: 919-783-8846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: NICOLE CALDWELL
Title or Position: CLINICAL DIRECTOR/OWNER
Credential: CCC/SLP
Phone: 919-783-8846