Healthcare Provider Details

I. General information

NPI: 1124550587
Provider Name (Legal Business Name): SAFE AND STABLE FAMILIES WELLNESS CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7825 MIDLOTHIAN TPKE STE 203
NORTH CHESTERFIELD VA
23235-5247
US

IV. Provider business mailing address

7825 MIDLOTHIAN TPKE STE 203
NORTH CHESTERFIELD VA
23235-5247
US

V. Phone/Fax

Practice location:
  • Phone: 229-412-8125
  • Fax:
Mailing address:
  • Phone: 229-412-8125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701006356
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0701006356
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701006356
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number0701006356
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0701006356
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0717001358
License Number StateVA
# 7
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701006356
License Number StateVA

VIII. Authorized Official

Name: MR. AGUSTIN J CRUZ
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LPC
Phone: 229-412-8125