Healthcare Provider Details

I. General information

NPI: 1578479788
Provider Name (Legal Business Name): INTENTIONAL WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 DAVID COX RD STE M
CHARLOTTE NC
28269-2282
US

IV. Provider business mailing address

6434 SPRINGBEAUTY DR
CHARLOTTE NC
28227-2573
US

V. Phone/Fax

Practice location:
  • Phone: 336-500-1570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: WHITTNEY WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 336-500-1570