Provider Demographics
NPI:1851774715
Name:VIDEO THERAPY
Entity Type:Organization
Organization Name:VIDEO THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SABRIYA
Authorized Official - Middle Name:LAILA
Authorized Official - Last Name:SHARIF-HANIFA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCASA
Authorized Official - Phone:919-758-4559
Mailing Address - Street 1:4749 COURTNEY LN APT F
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-5250
Mailing Address - Country:US
Mailing Address - Phone:919-758-4559
Mailing Address - Fax:919-573-0442
Practice Address - Street 1:4208 SIX FORKS RD STE 1000
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5738
Practice Address - Country:US
Practice Address - Phone:919-758-4559
Practice Address - Fax:919-573-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3175-A302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization