Provider Demographics
NPI:1285819946
Name:WAKE TEEN MEDICAL SERVICES INC.
Entity Type:Organization
Organization Name:WAKE TEEN MEDICAL SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-828-0035
Mailing Address - Street 1:505 OBERLIN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1397
Mailing Address - Country:US
Mailing Address - Phone:919-828-0035
Mailing Address - Fax:919-828-0355
Practice Address - Street 1:505 OBERLIN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1397
Practice Address - Country:US
Practice Address - Phone:919-828-0035
Practice Address - Fax:919-828-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005424Medicaid