Healthcare Provider Details

I. General information

NPI: 1649147190
Provider Name (Legal Business Name): SE WELLNESS & BEHAVIORAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 N FRONT ST STE 110
WILMINGTON NC
28401-3908
US

IV. Provider business mailing address

321 N FRONT ST STE 110
WILMINGTON NC
28401-3908
US

V. Phone/Fax

Practice location:
  • Phone: 910-297-1765
  • Fax:
Mailing address:
  • Phone: 910-297-1766
  • 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 State

VIII. Authorized Official

Name: SHANATA EDWARDS
Title or Position: THERAPIST
Credential: LCMHC, LCASA
Phone: 910-726-6584