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General NPI Number Information
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NPI Number | 1831874023
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Entity Type | Organization
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Legal Business Name | RECLAIM WELLNESS GROUP
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Dates
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Enumeration Date | 06/16/2023
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Last Update Date | 06/16/2023
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Provider Practice Location Address
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Address Line | 4010 DUPONT CIR STE 600
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City | LOUISVILLE
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State | KY
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Zip | 40207-4883
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Country | US
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Telephone | 502-758-9878
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Fax |
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Provider Business Mailing Address
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Address Line | 4010 DUPONT CIR STE 600
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City | LOUISVILLE
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State | KY
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Zip | 40207-4883
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Country | US
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Telephone | 502-758-9878
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | CLEMENT STREET RUSSELL
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Credential | PSYD
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Telephone | 502-777-3188
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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