Provider Demographics
NPI:1295254399
Name:WAKE INTEGRATIVE BEHAVIORAL MEDICINE, PC
Entity type:Organization
Organization Name:WAKE INTEGRATIVE BEHAVIORAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PHD, HSP
Authorized Official - Phone:414-847-9351
Mailing Address - Street 1:80 BLAKE BLVD UNIT 3038
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9599
Mailing Address - Country:US
Mailing Address - Phone:414-847-9351
Mailing Address - Fax:888-822-7227
Practice Address - Street 1:1107 SEVEN LAKES DRIVE
Practice Address - Street 2:
Practice Address - City:SEVEN LAKES
Practice Address - State:NC
Practice Address - Zip Code:27376
Practice Address - Country:US
Practice Address - Phone:414-847-9351
Practice Address - Fax:888-227-7795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3503103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3503OtherMY LICENSE