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General NPI Number Information
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NPI Number | 1255059937
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Entity Type | Organization
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Legal Business Name | ATLANTIC WELLNESS GROUP, LLC
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Dates
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Enumeration Date | 08/18/2022
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Last Update Date | 08/18/2022
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Provider Practice Location Address
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Address Line | 139 E BUCKINGHAM DR
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City | REHOBOTH BEACH
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State | DE
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Zip | 19971-1467
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Country | US
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Telephone | 302-270-6992
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Fax |
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Provider Business Mailing Address
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Address Line | 139 E BUCKINGHAM DR
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City | REHOBOTH BEACH
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State | DE
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Zip | 19971-1467
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Country | US
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Telephone | 302-270-6992
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MARY VAUGHN MOOR
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Credential | PSY.D.
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Telephone | 302-270-6992
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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