Provider Demographics
NPI:1275782831
Name:FUQUAY FAMILY COUNSELING, PLLC
Entity Type:Organization
Organization Name:FUQUAY FAMILY COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:919-412-7321
Mailing Address - Street 1:602 E ACADEMY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2382
Mailing Address - Country:US
Mailing Address - Phone:919-346-5357
Mailing Address - Fax:
Practice Address - Street 1:602 E ACADEMY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2382
Practice Address - Country:US
Practice Address - Phone:919-346-5357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-18
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135K8OtherBCBS
NC229376546OtherUNITED BEHAVIORAL HEALTH
NC2150812OtherCIGNA BEHAVIORAL HEALTH