=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962061150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEAGLASS WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2019
-----------------------------------------------------
Last Update Date | 03/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2301 DELANEY AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-772-6121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5027 WRIGHTSVILLE AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-7046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-599-6055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | RICK BARNEY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 828-772-6121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------