=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962945709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEADWATERS WELLNESS AND COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2016
-----------------------------------------------------
Last Update Date | 12/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 CUSHMAN ST SUITE 4J
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-456-2256
-----------------------------------------------------
Fax | 907-456-2260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 CUSHMAN ST STE 5
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-456-2256
-----------------------------------------------------
Fax | 907-456-2260
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LIZ PAWELKO
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 907-456-2256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PCOC613
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------