Healthcare Provider Details

I. General information

NPI: 1134399652
Provider Name (Legal Business Name): TRIUMPH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 S MADISON BLVD SUITE C2
ROXBORO NC
27573-5485
US

IV. Provider business mailing address

3210 FAIRHILL DR
RALEIGH NC
27612-3215
US

V. Phone/Fax

Practice location:
  • Phone: 336-597-2065
  • Fax: 336-597-2116
Mailing address:
  • Phone: 919-256-0824
  • Fax: 919-256-0833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNC

VIII. Authorized Official

Name: TALESHA ROLLOCK
Title or Position: PROVIDER ENROLLMENT SPECIALIST
Credential:
Phone: 919-256-0824