=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235905993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECEPTIVE THERAPEUTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2023
-----------------------------------------------------
Last Update Date | 12/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 207 W MILLBROOK RD STE 210
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-985-6474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 W MILLBROOK RD STE 210
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-985-6474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JOHN JAY BROWN JR.
-----------------------------------------------------
Credential | MSW,LCSWA
-----------------------------------------------------
Telephone | 919-985-6474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------