=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295443141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED FAMILY WELLNESS, TRAINING & CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2022
-----------------------------------------------------
Last Update Date | 11/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6444 KENDALL ST
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80003-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-572-8545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6444 KENDALL ST
-----------------------------------------------------
City | ARVADA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80003-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-572-8545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JAMES LEE PAVLIK JR.
-----------------------------------------------------
Credential | MA, CTTP
-----------------------------------------------------
Telephone | 224-572-8548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------