Healthcare Provider Details

I. General information

NPI: 1235704735
Provider Name (Legal Business Name): PWP HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 11/25/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 WEST GRAND AVE
CHICAGO IL
60622
US

IV. Provider business mailing address

621 BROAD ST
ALTAVISTA VA
24517-1855
US

V. Phone/Fax

Practice location:
  • Phone: 872-817-9858
  • Fax: 773-661-6993
Mailing address:
  • Phone: 434-608-2618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YOLANDA STONE
Title or Position: CO-OWNER
Credential:
Phone: 434-608-2618