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General NPI Number Information
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NPI Number | 1174400543
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Entity Type | Organization
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Legal Business Name | THE WELLNESS COLLECTIVE BOUTIQUE
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Dates
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Enumeration Date | 08/18/2025
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Last Update Date | 08/18/2025
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Provider Practice Location Address
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Address Line | 7901 4TH ST N STE 300
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City | ST PETERSBURG
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State | FL
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Zip | 33702-4399
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Country | US
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Telephone | 407-921-6276
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Fax |
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Provider Business Mailing Address
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Address Line | 5707 CREEK DALE DR
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City | ORLANDO
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State | FL
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Zip | 32810-3981
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Country | US
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Telephone | 407-921-6276
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | NYESHA LOGAN
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Credential | LCSW
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Telephone | 407-921-6276
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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