Provider Demographics
NPI:1467726448
Name:PEMBROKE CENTER FOR WELLNESS, INC
Entity Type:Organization
Organization Name:PEMBROKE CENTER FOR WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLA
Authorized Official - Middle Name:OLEHONNA
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHNP-BC
Authorized Official - Phone:910-775-9201
Mailing Address - Street 1:773 OLD MAIN RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8753
Mailing Address - Country:US
Mailing Address - Phone:910-775-9201
Mailing Address - Fax:910-521-8540
Practice Address - Street 1:773 OLD MAIN RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-8753
Practice Address - Country:US
Practice Address - Phone:910-775-9201
Practice Address - Fax:910-521-8540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0064391041C0700X
NCLMFT-1304106H00000X
NC5000705363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917311Medicaid