Healthcare Provider Details

I. General information

NPI: 1205509205
Provider Name (Legal Business Name): IMPACT WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 GALENA AVE
NORTH CHESTERFIELD VA
23237-4638
US

IV. Provider business mailing address

2700 GALENA AVE
NORTH CHESTERFIELD VA
23237-4638
US

V. Phone/Fax

Practice location:
  • Phone: 702-754-9136
  • Fax:
Mailing address:
  • Phone: 702-754-9136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP C STAFFORD
Title or Position: CEO
Credential:
Phone: 702-754-9063