Healthcare Provider Details

I. General information

NPI: 1609263953
Provider Name (Legal Business Name): FOUNDATION RESTORATION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9370 FALLS OF NEUSE RD STE 203
RALEIGH NC
27615-2487
US

IV. Provider business mailing address

9650 STRICKLAND RD SUITE 103-180
RALEIGH NC
27615-1902
US

V. Phone/Fax

Practice location:
  • Phone: 919-569-5820
  • Fax:
Mailing address:
  • Phone: 949-385-2711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1831
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLMFTA - 9080A
License Number StateNC

VIII. Authorized Official

Name: MRS. ASHLEY MCILWAIN
Title or Position: FOUNDER AND CEO
Credential: M.A., LMFTA
Phone: 919-569-5820