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General NPI Number Information
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NPI Number | 1750034294
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Entity Type | Organization
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Legal Business Name | PROVIDENTIAL CARE: CENTER FOR MENTAL WELLNESS, PLLC
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Dates
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Enumeration Date | 02/03/2022
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Last Update Date | 02/03/2022
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Provider Practice Location Address
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Address Line | 3340B ELLSWORTH DR
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City | GREENVILLE
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State | NC
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Zip | 27834-4944
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Country | US
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Telephone | 252-917-8182
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 30882
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City | GREENVILLE
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State | NC
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Zip | 27833-0882
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Country | US
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Telephone | 252-917-8182
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Fax |
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Authorized Official
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Title or Position | OWNER, CLINICIAN
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Name | MS. RICHELLE LAFAYE SMALLWOOD
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Credential | LCSW
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Telephone | 252-315-8081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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