Healthcare Provider Details

I. General information

NPI: 1801508809
Provider Name (Legal Business Name): INTEGRATE THERAPY AND WELLNESS COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3749 COUNTRY LN
GORDONVILLE PA
17529-9681
US

IV. Provider business mailing address

3749 COUNTRY LN
GORDONVILLE PA
17529-9681
US

V. Phone/Fax

Practice location:
  • Phone: 610-883-6005
  • Fax:
Mailing address:
  • Phone: 610-883-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMBUR GREGORIO
Title or Position: MENTAL HEALTH THERAPIST
Credential: LSW
Phone: 610-883-6005