Healthcare Provider Details

I. General information

NPI: 1356971022
Provider Name (Legal Business Name): TWO RIVERS WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1158 PROFESSIONAL DR STE K
WILLIAMSBURG VA
23185-6618
US

IV. Provider business mailing address

1158 PROFESSIONAL DR STE K
WILLIAMSBURG VA
23185-6618
US

V. Phone/Fax

Practice location:
  • Phone: 703-498-8675
  • Fax:
Mailing address:
  • Phone: 703-498-8675
  • 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: ROMINA ABAWI-WOOTEN
Title or Position: THERAPIST
Credential: LPC, CSAC, NCC
Phone: 703-498-8675