Healthcare Provider Details

I. General information

NPI: 1134077076
Provider Name (Legal Business Name): ENVISION SOLUTIONS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4492 MIDDLETOWN DR
WAKE FOREST NC
27587-4187
US

IV. Provider business mailing address

PO BOX 549
WAKE FOREST NC
27588-0549
US

V. Phone/Fax

Practice location:
  • Phone: 910-580-0594
  • Fax:
Mailing address:
  • Phone: 910-580-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA LORAINE BLANCO
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 910-580-0594