=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578479788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENTIONAL WELLNESS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2026
-----------------------------------------------------
Last Update Date | 08/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3509 DAVID COX RD STE M
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-2282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-500-1570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6434 SPRINGBEAUTY DR
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28227-2573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | WHITTNEY WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-500-1570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------