Healthcare Provider Details

I. General information

NPI: 1356829386
Provider Name (Legal Business Name): CORNERSTONE COUNSELING AND WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4286 WOODBINE RD STE A
PACE FL
32571-8770
US

IV. Provider business mailing address

5170 ANNIE RUTH ST
MILTON FL
32570-8153
US

V. Phone/Fax

Practice location:
  • Phone: 850-259-9501
  • Fax:
Mailing address:
  • Phone: 850-259-9501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name: HOWLAND ELLIS
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: L.C.S.W.
Phone: 850-259-9501