Provider Demographics
NPI:1588057798
Name:EPIPHANY MENTAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:EPIPHANY MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:252-435-5016
Mailing Address - Street 1:916 BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-5708
Mailing Address - Country:US
Mailing Address - Phone:252-985-0078
Mailing Address - Fax:252-446-6645
Practice Address - Street 1:916 BRANCH ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-5708
Practice Address - Country:US
Practice Address - Phone:252-985-0078
Practice Address - Fax:252-446-6645
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EPIPHANY MENTAL HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5054251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6103211Medicaid