Provider Demographics
NPI:1780191627
Name:COLLEGIAL BEHAVIORAL HEALTH, PLLC
Entity Type:Organization
Organization Name:COLLEGIAL BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-808-6428
Mailing Address - Street 1:12740 SPRUCE TREE WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8295
Mailing Address - Country:US
Mailing Address - Phone:919-916-1160
Mailing Address - Fax:919-488-4226
Practice Address - Street 1:12740 SPRUCE TREE WAY STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8295
Practice Address - Country:US
Practice Address - Phone:919-916-1160
Practice Address - Fax:919-488-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-01
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty