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General NPI Number Information
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NPI Number | 1104052901
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Entity Type | Organization
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Legal Business Name | PRIMARY SOURCE GROUP, PLLC
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Dates
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Enumeration Date | 06/08/2009
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Last Update Date | 07/25/2011
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Provider Practice Location Address
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Address Line | 4905 GREEN RD SUITE 105
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City | RALEIGH
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State | NC
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Zip | 27616-2805
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Country | US
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Telephone | 919-981-7373
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Fax | 919-981-7373
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Provider Business Mailing Address
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Address Line | PO BOX 58098
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City | RALEIGH
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State | NC
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Zip | 27658-8098
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Country | US
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Telephone | 919-434-3555
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Fax | 919-981-7373
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | LESLIE M HARDY
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Credential | MSW, LCSW, CSS
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Telephone | 919-434-3555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1222
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 1572
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 865
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License Number State | NC
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C003663
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License Number State | NC
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