Basic Information
| Provider Information | |||||||||
| NPI: | 1760536460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRIUMPH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3210 FAIRHILL DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276123215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192560824 | ||||||||
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| Practice Location | |||||||||
| Address1: | 119 W DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | MOCKSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270282327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367515636 | ||||||||
| FaxNumber: | 3367515696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 02/24/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROLLOCK | ||||||||
| AuthorizedOfficialFirstName: | TALESHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9192560824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6005576 | 05 | NC | MEDICAID |