=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669065645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORATIVE PSYCHOTHERAPY & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2021
-----------------------------------------------------
Last Update Date | 02/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4235 HILLSBORO PIKE STE 300
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37215-3344
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-568-5582
-----------------------------------------------------
Fax | 757-578-8237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2301 BEACH HAVEN DR APT 104
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-506-8362
-----------------------------------------------------
Fax | 757-578-8237
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NETSANET ABRAHA TEGEGN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-568-5582
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------