Provider Demographics
NPI:1295188175
Name:SYSTEMIC MEDIATIONS AND RESTORATIVE THERAPY
Entity Type:Organization
Organization Name:SYSTEMIC MEDIATIONS AND RESTORATIVE THERAPY
Other - Org Name:SMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LMFT, CERTIFIED FAMILY MEDIATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-960-7796
Mailing Address - Street 1:916 ARSENAL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:916 ARSENAL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5328
Practice Address - Country:US
Practice Address - Phone:910-960-7796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1368106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty