Provider Demographics
NPI:1538504238
Name:WAKE FOREST HEALTH NETWORK LLC
Entity Type:Organization
Organization Name:WAKE FOREST HEALTH NETWORK LLC
Other - Org Name:ATRIUM HEALTH WAKE FOREST BAPTIST BEHAVIORAL MEDICINE - FSLR PEDIATRIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP NETWORK PHYS & HS CMO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MARS
Authorized Official - Last Name:HOWERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-716-1331
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:2933 MAPLEWOOD AVE STE 1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4001
Practice Address - Country:US
Practice Address - Phone:336-802-2205
Practice Address - Fax:336-802-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty