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General NPI Number Information
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NPI Number | 1205276599
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Entity Type | Organization
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Legal Business Name | WAKE RENEWAL COUNSELING, PLLC
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Dates
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Enumeration Date | 07/01/2013
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Last Update Date | 07/01/2013
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Provider Practice Location Address
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Address Line | 1008 BIG OAK CT STE F
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City | KNIGHTDALE
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State | NC
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Zip | 27545-6566
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Country | US
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Telephone | 919-520-9392
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Fax | 919-261-1675
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Provider Business Mailing Address
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Address Line | 1008 BIG OAK CT STE F
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City | KNIGHTDALE
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State | NC
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Zip | 27545-6566
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Country | US
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Telephone | 919-520-9392
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Fax | 919-261-1675
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Authorized Official
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Title or Position | OWNTER/THERAPIST
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Name | MRS. KEISHA HINTON BRYAN
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Credential | LCSW, LCAS
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Telephone | 919-520-9392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C006619
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License Number State | NC
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