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General NPI Number Information
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NPI Number | 1184305898
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Entity Type | Organization
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Legal Business Name | MENTAL WELLNESS CLUB LLC
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Dates
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Enumeration Date | 07/26/2023
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 510 S FAIRMONT AVE SUITE 2
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City | LODI
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State | CA
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Zip | 95240
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Country | US
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Telephone | 209-471-3856
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Fax | 209-644-7606
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Provider Business Mailing Address
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Address Line | 7627 RIVER OTTER WAY
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City | ELK GROVE
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State | CA
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Zip | 95758
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Country | US
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Telephone | 209-471-3856
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Fax | 209-644-7606
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Authorized Official
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Title or Position | OWNER
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Name | MS. AWNEE MITCHELL
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Credential | MA LMFT PPS
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Telephone | 209-471-3856
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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