Healthcare Provider Details

I. General information

NPI: 1881047041
Provider Name (Legal Business Name): COMMUNITY WELLNESS COUNSELING AND SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10611 NW STATE ROAD 20
BRISTOL FL
32321-3441
US

IV. Provider business mailing address

10611 NW STATE ROAD 20
BRISTOL FL
32321-3441
US

V. Phone/Fax

Practice location:
  • Phone: 850-643-1033
  • Fax: 850-643-5066
Mailing address:
  • Phone: 850-643-1033
  • Fax: 850-643-5066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11921
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSW11921
License Number StateFL

VIII. Authorized Official

Name: MRS. WINTER LYNN COLLINS
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 850-643-7724