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General NPI Number Information
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NPI Number | 1780191627
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Entity Type | Organization
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Legal Business Name | COLLEGIAL BEHAVIORAL HEALTH, PLLC
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Dates
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Enumeration Date | 01/01/2018
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Last Update Date | 10/17/2019
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Provider Practice Location Address
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Address Line | 12740 SPRUCE TREE WAY STE 102
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City | RALEIGH
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State | NC
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Zip | 27614-8295
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Country | US
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Telephone | 919-916-1160
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Fax | 919-488-4226
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Provider Business Mailing Address
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Address Line | 12740 SPRUCE TREE WAY STE 102
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City | RALEIGH
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State | NC
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Zip | 27614-8295
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Country | US
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Telephone | 919-916-1160
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Fax | 919-488-4226
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MR. OWEN WANG
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Credential |
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Telephone | 626-808-6428
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-05553
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License Number State | NC
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