Healthcare Provider Details

I. General information

NPI: 1265001234
Provider Name (Legal Business Name): WOODSTREAM WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2021
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9049 SPRINGBORO PIKE
MIAMISBURG OH
45342-4418
US

IV. Provider business mailing address

9049 SPRINGBORO PIKE
MIAMISBURG OH
45342-4418
US

V. Phone/Fax

Practice location:
  • Phone: 937-759-0545
  • Fax:
Mailing address:
  • Phone: 937-759-0545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: EMILIE BREEDING
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 317-250-8709