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General NPI Number Information
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NPI Number | 1891267761
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Entity Type | Organization
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Legal Business Name | OLD TOWNE WELLNESS, LLC
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Dates
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Enumeration Date | 12/17/2018
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 7489 RIGHT FLANK RD STE 330
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-3845
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Country | US
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Telephone | 804-938-8884
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Fax | 804-789-8881
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Provider Business Mailing Address
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Address Line | 7489 RIGHT FLANK RD STE 330
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City | MECHANICSVILLE
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State | VA
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Zip | 23116-3845
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Country | US
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Telephone | 804-938-8884
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Fax | 804-789-8881
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Authorized Official
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Title or Position | OWNER
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Name | MS. JERI D LEWIS
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Credential | LPC
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Telephone | 804-938-8884
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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