=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649694357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMINENCE CONSULTING & THERAPUTIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2014
-----------------------------------------------------
Last Update Date | 02/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4909 WATERS EDGE DR 204
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-2462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-841-8679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4909 WATERS EDGE DR 204
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-2462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-841-8679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | COURTNEY STRICKLAND
-----------------------------------------------------
Credential | MSW, LCAS, LCSWA,
-----------------------------------------------------
Telephone | 919-841-8679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1577
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1577
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------