=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174996847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANCHORED IN WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2015
-----------------------------------------------------
Last Update Date | 11/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 E CHERRY ST
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31546-4872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-530-8889
-----------------------------------------------------
Fax | 912-598-6109
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 E CHERRY ST
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31546-4872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-530-8889
-----------------------------------------------------
Fax | 912-598-6109
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAUNA MATTINGLY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 912-530-8889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW003662
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------