Provider Demographics
NPI:1730859513
Name:SIMPLY TEEN OUTPATIENT
Entity type:Organization
Organization Name:SIMPLY TEEN OUTPATIENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KINNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MRC, LCMHCS
Authorized Official - Phone:919-869-5301
Mailing Address - Street 1:800 W WILLIAMS ST STE 203
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-5200
Mailing Address - Country:US
Mailing Address - Phone:919-869-5301
Mailing Address - Fax:855-678-6632
Practice Address - Street 1:800 W WILLIAMS ST STE 203
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-5200
Practice Address - Country:US
Practice Address - Phone:919-869-5301
Practice Address - Fax:855-678-6632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health