Provider Demographics
NPI:1871119784
Name:CAROLINA BRAIN WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:CAROLINA BRAIN WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN LUNDMARK
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:919-205-8325
Mailing Address - Street 1:131 CHARLOTTE AVE STE 101B
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4363
Mailing Address - Country:US
Mailing Address - Phone:919-205-8325
Mailing Address - Fax:
Practice Address - Street 1:131 CHARLOTTE AVE STE 101B
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4363
Practice Address - Country:US
Practice Address - Phone:919-205-8325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty