=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710197561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESIDENTIAL ADOLESCENT ADULT SERVICES AND TRAINING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 W MILLBROOK RD SUITE F
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-329-2630
-----------------------------------------------------
Fax | 919-329-2631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 W MILLBROOK RD SUITE F
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27609-4381
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-329-2630
-----------------------------------------------------
Fax | 919-329-2631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER CEO
-----------------------------------------------------
Name | MR. IGNACIO ROBERTO KIRK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-696-6071
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MHL-092-503
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------