Provider Demographics
NPI:1588156137
Name:TIRZAH WELLNESS CENTER, PLLC
Entity type:Organization
Organization Name:TIRZAH WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:910-520-6083
Mailing Address - Street 1:3205 RANDALL PKWY STE 121
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2567
Mailing Address - Country:US
Mailing Address - Phone:910-782-8042
Mailing Address - Fax:910-782-8042
Practice Address - Street 1:3205 RANDALL PKWY STE 121
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2567
Practice Address - Country:US
Practice Address - Phone:910-782-8042
Practice Address - Fax:910-782-8042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
NC251B00000X
NCC011298251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No251B00000XAgenciesCase Management