=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669386827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUGENE WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2026
-----------------------------------------------------
Last Update Date | 10/02/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 CRESTVIEW RD
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31833-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-585-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 CRESTVIEW RD
-----------------------------------------------------
City | WEST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31833-5221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-585-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | SUMMER MOON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 706-585-0204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------