Provider Demographics
NPI:1205276599
Name:WAKE RENEWAL COUNSELING, PLLC
Entity type:Organization
Organization Name:WAKE RENEWAL COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNTER/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:HINTON
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCAS
Authorized Official - Phone:919-520-9392
Mailing Address - Street 1:1008 BIG OAK CT STE F
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-6566
Mailing Address - Country:US
Mailing Address - Phone:919-520-9392
Mailing Address - Fax:919-261-1675
Practice Address - Street 1:1008 BIG OAK CT STE F
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-6566
Practice Address - Country:US
Practice Address - Phone:919-520-9392
Practice Address - Fax:919-261-1675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0066191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112015Medicaid
NC6112015Medicaid