=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578797536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WAKE COUNSELING ASSOCIATES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2009
-----------------------------------------------------
Last Update Date | 05/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2304 S MIAMI BLVD STE 223
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27703-4915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 191-920-0609
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1215
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. BONNIE ANN FITTS
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 19192006091
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6803
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------