=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144119041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GENERATIONAL HEALING AND WELLNESS THERAPY AND CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2025
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 FROW DR
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29045-7153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-697-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 636 FROW DR
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29045-7153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-697-4465
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JERICHA PETERSON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 843-697-4465
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------