Provider Demographics
NPI:1295870194
Name:EMBRENCHE LLC
Entity type:Organization
Organization Name:EMBRENCHE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-624-9618
Mailing Address - Street 1:1001 S MARSHALL ST STE 262
Mailing Address - Street 2:1001 S MARSHALL STREET SUITE 262
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5852
Mailing Address - Country:US
Mailing Address - Phone:336-722-8055
Mailing Address - Fax:336-722-4161
Practice Address - Street 1:1001 S MARSHALL ST STE 262
Practice Address - Street 2:1001 S MARSHALL STREET SUITE 262
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-5852
Practice Address - Country:US
Practice Address - Phone:336-722-8055
Practice Address - Fax:336-722-4161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005992Medicaid