Healthcare Provider Details

I. General information

NPI: 1124873120
Provider Name (Legal Business Name): TRANSFORMATIVE TREK THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 SE 180TH AVE
MORRISTON FL
32668-5257
US

IV. Provider business mailing address

21 HOLLY BERRY RD
FREDERICKSBURG VA
22406-5340
US

V. Phone/Fax

Practice location:
  • Phone: 352-316-7204
  • Fax:
Mailing address:
  • Phone: 352-316-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: PAIGE ASHLEY MARKHAM UEBELE
Title or Position: OWNER
Credential:
Phone: 352-316-7204