MEDICARE: DIASPORA HEALTH AND 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1073260550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIASPORA HEALTH AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	7385 STATE ROUTE 3 UNIT 326
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43082-8654
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 W BROAD ST # 1148
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43215-2759
Country	:	US
Telephone Number	:	740-825-0774
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSSELYN WEST
Credential	:	LSW
Telephone Number	:	740-825-0774

Provider Enumeration Date	:	03/04/2022
Last Update Date	:	03/21/2022

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