=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245795897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELSHEN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 02/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 FAYETTEVILLE ST
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27601-3030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-268-1011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 WRENN DR # 2022
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27511-5433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-268-1011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIAM ELSHENAWY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 919-637-1319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------