Healthcare Provider Details

I. General information

NPI: 1659113694
Provider Name (Legal Business Name): MINDFUL COUNSELING PROFESSIONALS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S WHITE ST
WAKE FOREST NC
27587-2920
US

IV. Provider business mailing address

525 S WHITE ST
WAKE FOREST NC
27587-2920
US

V. Phone/Fax

Practice location:
  • Phone: 919-372-4676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LATOYA TOLLER
Title or Position: OWNER
Credential: LCMHC
Phone: 919-264-1430