Provider Demographics
NPI:1851586044
Name:WARD, RENWICK BRUCE (QMHP)
Entity Type:Individual
Prefix:MR
First Name:RENWICK
Middle Name:BRUCE
Last Name:WARD
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 COLDWATER SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8419
Mailing Address - Country:US
Mailing Address - Phone:919-345-0045
Mailing Address - Fax:919-266-5469
Practice Address - Street 1:3501 NEPTUNE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-3907
Practice Address - Country:US
Practice Address - Phone:919-345-0045
Practice Address - Fax:919-266-5469
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL092685171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604185Medicaid