Healthcare Provider Details

I. General information

NPI: 1205425733
Provider Name (Legal Business Name): AERIAL WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 SAINT GEORGE SQUARE CT STE 300
WINSTON-SALEM NC
27103
US

IV. Provider business mailing address

615 SAINT GEORGE SQUARE CT STE 300
WINSTON-SALEM NC
27103
US

V. Phone/Fax

Practice location:
  • Phone: 336-441-7392
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: TRISTIAN WEBB
Title or Position: CEO, PRINCIPAL PSYCHOTHERAPIST
Credential:
Phone: 336-441-7392