Healthcare Provider Details

I. General information

NPI: 1265132088
Provider Name (Legal Business Name): NOURISH WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 LAKESHORE VILLAGE DR
SLIDELL LA
70461-6605
US

IV. Provider business mailing address

163 PARKHOUSE ST
DALLAS TX
75207-7211
US

V. Phone/Fax

Practice location:
  • Phone: 504-491-8963
  • Fax:
Mailing address:
  • Phone: 504-491-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TELITA OVIDE
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: MSW
Phone: 504-491-8963