=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073242111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARROWHEAD EMOTIONAL WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2022
-----------------------------------------------------
Last Update Date | 06/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 634 PENN AVE
-----------------------------------------------------
City | WEST READING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19611-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-709-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 634 PENN AVE
-----------------------------------------------------
City | WEST READING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19611-1004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-709-2441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. KELLY NIXON BURNS
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 484-709-2441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------