Healthcare Provider Details

I. General information

NPI: 1558015305
Provider Name (Legal Business Name): ELEMENTAL HEALTH CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 RANDALL PKWY
WILMINGTON NC
28403-2829
US

IV. Provider business mailing address

5030 RANDALL PKWY
WILMINGTON NC
28403-2829
US

V. Phone/Fax

Practice location:
  • Phone: 910-240-4757
  • Fax:
Mailing address:
  • Phone: 910-240-4757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QM1000X
TaxonomyMigrant Health Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: HAVAH ISABEL HENZLER
Title or Position: OWNER
Credential: LCSW, LCAS
Phone: 910-599-4017