Healthcare Provider Details

I. General information

NPI: 1497422703
Provider Name (Legal Business Name): SIMPLY WELL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 12/11/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 BARRETT DR
RALEIGH NC
27609-6604
US

IV. Provider business mailing address

4070 BARRETT DR
RALEIGH NC
27609-6604
US

V. Phone/Fax

Practice location:
  • Phone: 919-410-6566
  • Fax:
Mailing address:
  • Phone: 919-410-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MALLORI THOMPSON
Title or Position: GENERAL MANAGER
Credential:
Phone: 919-410-6566