=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134884265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEAR RUN COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2920 FORESTVILLE RD STE 100-1212
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27616-8774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-526-0276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4944 BROWN DR
-----------------------------------------------------
City | KAILUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96734-6259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-222-4067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/ORGANIZER
-----------------------------------------------------
Name | ANGEL PORTER
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 919-526-0276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------