Provider Demographics
NPI:1972825867
Name:PROVIDENCE COUNSELING SERVICES
Entity Type:Organization
Organization Name:PROVIDENCE COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:LANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:919-924-1221
Mailing Address - Street 1:1600 SPENNYMORE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-9234
Mailing Address - Country:US
Mailing Address - Phone:919-772-4490
Mailing Address - Fax:
Practice Address - Street 1:1401 RAVENSTHORPE DR
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-7714
Practice Address - Country:US
Practice Address - Phone:919-924-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6595101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103669Medicaid