Healthcare Provider Details

I. General information

NPI: 1134947237
Provider Name (Legal Business Name): HOUSE OF WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 TWO NOTCH RD STE 5
COLUMBIA SC
29223-1612
US

IV. Provider business mailing address

9600 TWO NOTCH RD SUITE 5 #1072
COLUMBIA SC
29223-1612
US

V. Phone/Fax

Practice location:
  • Phone: 803-427-1979
  • Fax:
Mailing address:
  • Phone: 803-427-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DISHA BENN-PEAY
Title or Position: CO-OWNER
Credential: LISW-CP
Phone: 803-427-1979