=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881348415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELL BEING PHYSICIAN ASSISTANT MENTAL HEALTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2022
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6613B BAY LAUREL PL
-----------------------------------------------------
City | AVILA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93424-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-358-9992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 5TH ST
-----------------------------------------------------
City | LOS OSOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93402-1611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-358-9992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANTHONY THOMAS WHALL
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 561-358-9992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------