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General NPI Number Information
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NPI Number | 1528696796
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Entity Type | Organization
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Legal Business Name | FAITH SPRINGS ETERNAL (FASE), PLLC
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Dates
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Enumeration Date | 04/01/2020
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Last Update Date | 07/01/2021
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Provider Practice Location Address
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Address Line | 910 HOPE MILLS RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-4243
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Country | US
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Telephone | 919-888-6397
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Fax |
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Provider Business Mailing Address
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Address Line | 910 HOPE MILLS RD
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City | FAYETTEVILLE
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State | NC
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Zip | 28304-4243
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Country | US
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Telephone | 919-888-6397
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IMANI NIA JOHNSON
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Credential |
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Telephone | 678-612-6699
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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