Healthcare Provider Details

I. General information

NPI: 1043889595
Provider Name (Legal Business Name): CGL WELLNESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2021
Last Update Date: 06/20/2021
Certification Date: 06/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8435 CEDAR MDWS
SAN ANTONIO TX
78254-6285
US

IV. Provider business mailing address

P.O BOX 40522 12245 BEECH DALY RD.
REDFORD MI
48239
US

V. Phone/Fax

Practice location:
  • Phone: 210-742-7123
  • Fax:
Mailing address:
  • Phone: 313-247-8850
  • 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: REBEKA LYNN HUGHES
Title or Position: FOUNDER/EXECUTIVE DIRECTOR
Credential: LPC
Phone: 313-247-8840