Healthcare Provider Details

I. General information

NPI: 1750683694
Provider Name (Legal Business Name): CHARIS FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

9621 SIX FORKS RD
RALEIGH NC
27615-1628
US

IV. Provider business mailing address

7716 FALL BRANCH CT
WAKE FOREST NC
27587-8719
US

V. Phone/Fax

Practice location:
  • Phone: 919-671-4374
  • Fax:
Mailing address:
  • Phone: 919-556-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3964
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number488
License Number StateNC

VIII. Authorized Official

Name: FRANK GREEN
Title or Position: FOUNDER
Credential: D.MIN, LMFT
Phone: 919-556-9141