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General NPI Number Information
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NPI Number | 1871119784
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Entity Type | Organization
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Legal Business Name | CAROLINA BRAIN WELLNESS CENTER PLLC
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Dates
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Enumeration Date | 06/17/2020
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Last Update Date | 06/17/2020
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Provider Practice Location Address
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Address Line | 131 CHARLOTTE AVE STE 101B
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City | SANFORD
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State | NC
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Zip | 27330-4363
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Country | US
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Telephone | 919-205-8325
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Fax |
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Provider Business Mailing Address
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Address Line | 131 CHARLOTTE AVE STE 101B
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City | SANFORD
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State | NC
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Zip | 27330-4363
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Country | US
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Telephone | 919-205-8325
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Fax |
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Authorized Official
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Title or Position | NEUROPSYCHOLOGIST
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Name | DR. JENNIFER LYNN LUNDMARK RICHARDS
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Credential | PH.D.
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Telephone | 919-205-8325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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