Provider Demographics
NPI:1881728012
Name:TRIAD THERAPY, LLC
Entity type:Organization
Organization Name:TRIAD THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINCY
Authorized Official - Middle Name:ROCHELLE
Authorized Official - Last Name:SMILING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:336-896-0904
Mailing Address - Street 1:PO BOX 12595
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27117-2595
Mailing Address - Country:US
Mailing Address - Phone:803-720-4028
Mailing Address - Fax:
Practice Address - Street 1:7830 N POINT BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3261
Practice Address - Country:US
Practice Address - Phone:336-896-0904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 101YM0800X
NCC0018371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006089Medicaid