Healthcare Provider Details

I. General information

NPI: 1457519514
Provider Name (Legal Business Name): ADOLESCENT,CHILD & ADULT PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 05/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 ED DR # 108
RALEIGH NC
27612-8089
US

IV. Provider business mailing address

4041 ED DR # 108
RALEIGH NC
27612-8089
US

V. Phone/Fax

Practice location:
  • Phone: 919-783-8377
  • Fax: 866-347-8377
Mailing address:
  • Phone: 919-783-8377
  • Fax: 866-347-8377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number28114
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number28114
License Number StateNC

VIII. Authorized Official

Name: DR. SHAHEDA FATIMA MAROOF
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 919-783-8377