=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528644713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSPIRED WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2021
-----------------------------------------------------
Last Update Date | 03/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7511 SAINT ANDREWS RD STE 4
-----------------------------------------------------
City | IRMO
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29063-2894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-575-0579
-----------------------------------------------------
Fax | 803-830-3873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 EVERTON DR
-----------------------------------------------------
City | CHAPIN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29036-7124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-542-4152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELA JACKSON
-----------------------------------------------------
Credential | LISW-CP
-----------------------------------------------------
Telephone | 803-542-4152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------