Provider Demographics
NPI:1285452375
Name:THERAPEUTIC VILLAGE LLC
Entity type:Organization
Organization Name:THERAPEUTIC VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEYMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CRISP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-510-0653
Mailing Address - Street 1:8386 SIX FORKS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5088
Mailing Address - Country:US
Mailing Address - Phone:336-933-1204
Mailing Address - Fax:336-510-0926
Practice Address - Street 1:8386 SIX FORKS RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5088
Practice Address - Country:US
Practice Address - Phone:336-933-1204
Practice Address - Fax:336-510-0926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-28
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty