Healthcare Provider Details

I. General information

NPI: 1053184507
Provider Name (Legal Business Name): THE WOW WORKSHOP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 UNION RD STE C
GASTONIA NC
28054-6804
US

IV. Provider business mailing address

1108 UNION RD STE C
GASTONIA NC
28054-6804
US

V. Phone/Fax

Practice location:
  • Phone: 786-663-1195
  • Fax:
Mailing address:
  • Phone: 786-663-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MARTHA BIVIANA GAVIRIA
Title or Position: FOUNDER
Credential:
Phone: 786-663-1195