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General NPI Number Information
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NPI Number | 1083072250
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Entity Type | Organization
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Legal Business Name | GREEN MEADOWS WELLNESS CENTER LLC
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Dates
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Enumeration Date | 02/03/2016
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Last Update Date | 02/03/2016
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Provider Practice Location Address
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Address Line | 1640 MEADOW CREEK ROAD
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City | WOODBINE
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State | KY
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Zip | 40771
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Country | US
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Telephone | 606-280-5581
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 98
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City | WOODBINE
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State | KY
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Zip | 40771-0098
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Country | US
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Telephone | 606-280-5581
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Fax |
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Authorized Official
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Title or Position | SOLE MBR.
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Name | SANDRA NANTZ
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Credential |
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Telephone | 606-280-5581
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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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