Healthcare Provider Details

I. General information

NPI: 1417387796
Provider Name (Legal Business Name): ITHERAPYRX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2013
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 ATWOOD ST
SPARTA NC
28675-9299
US

IV. Provider business mailing address

PO BOX 56
ROARING GAP NC
28668-0056
US

V. Phone/Fax

Practice location:
  • Phone: 828-964-8790
  • Fax:
Mailing address:
  • Phone: 828-964-8790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3453
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number3453
License Number StateNC

VIII. Authorized Official

Name: MS. CAROL KELLEY PULLEY
Title or Position: LICENSED PSYCHOLOGICAL ASSOCIATE
Credential: L.P.A.
Phone: 828-964-8790