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General NPI Number Information
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NPI Number | 1467840181
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Entity Type | Organization
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Legal Business Name | PSYCHOTHERAPY & WELLNESS GROUP
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 390 VILLAGE FARMS LN
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City | FOLSOM
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State | LA
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Zip | 70437-6118
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Country | US
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Telephone | 985-796-7006
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Fax | 985-235-0086
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Provider Business Mailing Address
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Address Line | 390 VILLAGE FARMS LN
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City | FOLSOM
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State | LA
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Zip | 70437-6118
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Country | US
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Telephone | 985-796-7006
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Fax | 985-235-0086
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Authorized Official
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Title or Position | OWNER/COUNSELOR
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Name | NATHAN PAUL HENNICK
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Credential | M.ED.
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Telephone | 985-796-7006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 5023
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11190
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4920
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License Number State | LA
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