MEDICARE: BROWN SUGAR WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053934000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROWN SUGAR WELLNESS, LLC

Provider Business Mailing Address
First Line	:	9008 N 78TH ST APT B
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33637-6413
Country	:	US
Telephone Number	:	813-532-0281
Fax Number	:

Provider Business Practice Location Address
First Line	:	6408 N ARMENIA AVE STE E-1
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-5770
Country	:	US
Telephone Number	:	813-679-6279
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. PHEKILA JOHNSON
Credential	:	LMHC
Telephone Number	:	813-679-6279

Provider Enumeration Date	:	05/26/2020
Last Update Date	:	09/16/2020

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