=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043889595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CGL WELLNESS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2021
-----------------------------------------------------
Last Update Date | 06/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8435 CEDAR MDWS
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78254-6285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-742-7123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O BOX 40522 12245 BEECH DALY RD.
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-247-8850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | REBEKA LYNN HUGHES
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 313-247-8840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------