Healthcare Provider Details

I. General information

NPI: 1962945709
Provider Name (Legal Business Name): HEADWATERS WELLNESS AND COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2016
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CUSHMAN ST SUITE 4J
FAIRBANKS AK
99701-4665
US

IV. Provider business mailing address

250 CUSHMAN ST STE 5
FAIRBANKS AK
99701-4665
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-2256
  • Fax: 907-456-2260
Mailing address:
  • Phone: 907-456-2256
  • Fax: 907-456-2260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCOC613
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LIZ PAWELKO
Title or Position: OWNER
Credential: LPC
Phone: 907-456-2256