Healthcare Provider Details

I. General information

NPI: 1295870194
Provider Name (Legal Business Name): EMBRENCHE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S MARSHALL ST STE 262 1001 S MARSHALL STREET SUITE 262
WINSTON SALEM NC
27101-5852
US

IV. Provider business mailing address

1001 S MARSHALL ST STE 262 1001 S MARSHALL STREET SUITE 262
WINSTON SALEM NC
27101-5852
US

V. Phone/Fax

Practice location:
  • Phone: 336-722-8055
  • Fax: 336-722-4161
Mailing address:
  • Phone: 336-722-8055
  • Fax: 336-722-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTY HICKMAN
Title or Position: DIRECTOR
Credential:
Phone: 336-624-9618