Provider Demographics
NPI:1992016000
Name:INNERPATH
Entity Type:Organization
Organization Name:INNERPATH
Other - Org Name:INNERPATH FAMILY COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-301-0054
Mailing Address - Street 1:5840 FARINGDON PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-3930
Mailing Address - Country:US
Mailing Address - Phone:919-301-0054
Mailing Address - Fax:919-347-8606
Practice Address - Street 1:5840 FARINGDON PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3930
Practice Address - Country:US
Practice Address - Phone:919-301-0054
Practice Address - Fax:919-347-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC005512251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health