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General NPI Number Information
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NPI Number | 1689918641
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Entity Type | Organization
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Legal Business Name | CREECH ROAD SUPERVISED GARE
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 311 NEW BERN AVE # 27991
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City | RALEIGH
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State | NC
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Zip | 27611-0801
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Country | US
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Telephone | 919-961-1392
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Fax |
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Provider Business Mailing Address
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Address Line | 808 CREECH RD
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City | GARNER
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State | NC
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Zip | 27529-2916
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Country | US
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Telephone | 919-961-1392
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. EZEKIEL WILSON JR.
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Credential |
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Telephone | 919-961-1392
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MHL 092761
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License Number State | NC
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