Healthcare Provider Details

I. General information

NPI: 1992374896
Provider Name (Legal Business Name): OPTIMAL BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 06/23/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7203 MONARDA CT
RALEIGH NC
27616-8697
US

IV. Provider business mailing address

7203 MONARDA CT
RALEIGH NC
27616-8697
US

V. Phone/Fax

Practice location:
  • Phone: 919-793-5862
  • Fax:
Mailing address:
  • Phone: 919-793-5862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA EZEWUZIE
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: NP
Phone: 919-793-5862