NPIMap

Organization Active NPI

Primary Source Group, PLLC

  • Clinical Social Worker
  • Raleigh, NC
National Provider Identifier
1104052901
Registry record updated Jul 25, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
License
C003663 Issued in NC
Legal business name
PRIMARY SOURCE GROUP, PLLC
Practice address
4905 Green Rd
Suite 105
Raleigh, NC 27616-2805
Phone
(919) 981-7373
Fax
(919) 981-7373
NPI assigned
Jun 8, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 25, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Leslie M Hardy, MSW, LCSW, CSSNPI 1295865459
Title
President/Owner
Phone
(919) 434-3555

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X 1222 NC
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X 1572 NC
Counseling PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC1900X 865 NC
Clinical Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 1041C0700X C003663 NC Primary

Addresses

Primary practice location

4905 Green Rd
Suite 105
Raleigh, NC 27616-2805

Mailing address

PO Box 58098
Raleigh, NC 27658-8098
Phone (919) 434-3555

Other identifiers 1

IdentifierTypeStateIssuer
6106329MedicaidNC

National Provider Directory

National Provider Directory

Locations

4905 Green Rd
Ste 105
Raleigh, NC 27616
Phone (919) 981-7373

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1244419200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1311552000000",
    "number": "1104052901",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 58098",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276588098",
            "telephone_number": "919-434-3555",
            "fax_number": "919-981-7373"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4905 GREEN RD",
            "address_2": "SUITE 105",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276162805",
            "telephone_number": "919-981-7373",
            "fax_number": "919-981-7373"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRIMARY SOURCE GROUP, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-06-08",
        "last_updated": "2011-07-25",
        "status": "A",
        "authorized_official_last_name": "HARDY",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT/OWNER",
        "authorized_official_telephone_number": "919-434-3555",
        "authorized_official_credential": "MSW, LCSW, CSS"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "NC",
            "license": "1222",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": "NC",
            "license": "1572",
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": "NC",
            "license": "865",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": "NC",
            "license": "C003663",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6106329",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Raleigh, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.