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General NPI Number Information
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NPI Number | 1851774715
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Entity Type | Organization
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Legal Business Name | VIDEO THERAPY
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Dates
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Enumeration Date | 07/09/2015
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Last Update Date | 07/09/2015
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Provider Practice Location Address
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Address Line | 4208 SIX FORKS RD STE 1000
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City | RALEIGH
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State | NC
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Zip | 27609-5738
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Country | US
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Telephone | 919-758-4559
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Fax | 919-573-0442
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Provider Business Mailing Address
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Address Line | 4749 COURTNEY LN APT F
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City | RALEIGH
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State | NC
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Zip | 27616-5250
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Country | US
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Telephone | 919-758-4559
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Fax | 919-573-0442
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Authorized Official
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Title or Position | CEO
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Name | MRS. SABRIYA LAILA SHARIF-HANIFA
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Credential | MS, LCASA
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Telephone | 919-758-4559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 3175-A
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License Number State | NC
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