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General NPI Number Information
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NPI Number | 1780462473
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Entity Type | Organization
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Legal Business Name | INTERCONNECTION WELLNESS LLC
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Dates
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Enumeration Date | 09/15/2023
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Last Update Date | 01/19/2024
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Provider Practice Location Address
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Address Line | 113 S PERRY ST STE 206
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4811
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Country | US
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Telephone | 470-326-6717
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Fax |
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Provider Business Mailing Address
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Address Line | 113 S PERRY ST SUITE 206 #9320
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-4811
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Country | US
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Telephone | 470-369-0957
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Fax |
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Authorized Official
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Title or Position | CLINICAL SOCIAL WORKER
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Name | KRISTAL ALEXIS LEWIS
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Credential | LCSW
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Telephone | 470-369-0957
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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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