Healthcare Provider Details

I. General information

NPI: 1760116297
Provider Name (Legal Business Name): LOOK INSIDE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 N BROAD ST STE E # 10104
LURAY VA
22835-1162
US

IV. Provider business mailing address

PO BOX 806054
SAINT CLAIR SHORES MI
48080-6054
US

V. Phone/Fax

Practice location:
  • Phone: 571-449-7837
  • Fax:
Mailing address:
  • Phone: 571-449-7837
  • Fax: 571-449-7837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUDITH PATRICIA WATTA
Title or Position: OWNER
Credential: LCSW
Phone: 571-449-7837