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General NPI Number Information
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NPI Number | 1013696012
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Entity Type | Organization
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Legal Business Name | K & M WELLNESS, INC
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Dates
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Enumeration Date | 07/17/2023
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Last Update Date | 07/27/2023
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Provider Practice Location Address
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Address Line | #186 MOHAWK ACRES PLAZA 1756 BLACK RIVER BLVD
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City | ROME
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State | NY
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Zip | 13440
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Country | US
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Telephone | 315-220-0603
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Fax |
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Provider Business Mailing Address
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Address Line | #186 MOHAWK ACRES PLAZA 1756 BLACK RIVER BLVD
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City | ROME
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State | NY
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Zip | 13440
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Country | US
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Telephone | 315-220-0603
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. LATREASE R MOORE
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Credential | PHD
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Telephone | 315-220-0603
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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