Provider Demographics
NPI:1366793895
Name:FOUNDATIONS FAMILY THERAPY OF NORTH CAROLINA, PLLC
Entity type:Organization
Organization Name:FOUNDATIONS FAMILY THERAPY OF NORTH CAROLINA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED MARRIAGE AND FAMILY
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:CRISWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:919-285-4802
Mailing Address - Street 1:PO BOX 1927
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-2927
Mailing Address - Country:US
Mailing Address - Phone:919-285-4802
Mailing Address - Fax:
Practice Address - Street 1:206 RALEIGH ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-2263
Practice Address - Country:US
Practice Address - Phone:919-285-4802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1451251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health