Healthcare Provider Details

I. General information

NPI: 1609499243
Provider Name (Legal Business Name): ELIZABETH RANGANAI MAVINDIDZE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAKEMED HEALTH AND HOSPITALS 3000 NEW BERN AVENUE
RALEIGH NC
27610
US

IV. Provider business mailing address

3444 BARN RD
APEX NC
27502-7403
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-7722
  • Fax:
Mailing address:
  • Phone: 610-772-3734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberC010695
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: