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General NPI Number Information
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NPI Number | 1609340876
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Entity Type | Organization
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Legal Business Name | WELLNESS INTEGRATIVE SUPPORTIVE RESOURCES, LLC
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Dates
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Enumeration Date | 01/21/2019
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Last Update Date | 02/21/2024
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Provider Practice Location Address
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Address Line | 8022 CLOVERTREE CT
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-5382
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Country | US
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Telephone | 804-304-4778
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Fax |
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Provider Business Mailing Address
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Address Line | 8022 CLOVERTREE CT
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23235-5382
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Country | US
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Telephone | 804-304-4778
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MS. BEVERLY LYNESE AGNESS
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Credential | QMHP-A
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Telephone | 804-304-4778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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