Provider Demographics
NPI:1104254234
Name:MAN IN THE MIRROR THERAPEUTIC SERVICES
Entity type:Organization
Organization Name:MAN IN THE MIRROR THERAPEUTIC SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:VONCYLE
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:919-798-4659
Mailing Address - Street 1:312 W MILLBROOK RD
Mailing Address - Street 2:SUITE 137
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4389
Mailing Address - Country:US
Mailing Address - Phone:919-798-4659
Mailing Address - Fax:
Practice Address - Street 1:312 W MILLBROOK RD
Practice Address - Street 2:SUITE 137
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4389
Practice Address - Country:US
Practice Address - Phone:919-798-4659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VALERIE COPELAND
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1499106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1568805216Medicaid