=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326779612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS WITHIN, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2022
-----------------------------------------------------
Last Update Date | 06/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2039 REGENCY RD STE 3
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-2334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-659-0002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2523 MABLE LN
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40511-8366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-396-2031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. SHERICKA DANIELLE SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 859-396-2031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0005X
-----------------------------------------------------
Taxonomy Name | Ambulatory Family Planning Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------