MEDICARE: I-THRIVE THERAPY 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1124651930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I-THRIVE THERAPY AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	4036 RAVINE GAP DR
Second Line	:
City	:	SUFFOLK
State	:	VA
Zip	:	23434-3050
Country	:	US
Telephone Number	:	401-359-1739
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 OLD GREENBRIER RD STE 107
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-2649
Country	:	US
Telephone Number	:	757-761-9425
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NATASHA EWA
Credential	:	LCSW
Telephone Number	:	757-761-9425

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	12/31/2020

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