=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043088081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENTIONAL WELLNESS PSYCHOTHERAPY LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2023
-----------------------------------------------------
Last Update Date | 12/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19 W 45TH ST STE 302
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10036-4904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-998-4206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 635 RIVERSIDE DR APT 6C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10031-7118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-998-4206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | AMY GOTTHEIMER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 347-998-4206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------