MEDICARE: THE WELLNESS COLLABORATIVE

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	0717001246	VA

General Provider Information

NPI Number	:	1396149829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE WELLNESS COLLABORATIVE

Provider Business Mailing Address
First Line	:	PO BOX 6892
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-0892
Country	:	US
Telephone Number	:	757-412-7753
Fax Number	:	757-301-6920

Provider Business Practice Location Address
First Line	:	1664 CHESTWOOD DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-7064
Country	:	US
Telephone Number	:	757-412-7753
Fax Number	:	757-301-6920

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JONATHAN ERIC SMITH
Credential	:	PHD, LMFT
Telephone Number	:	757-412-7753

Provider Enumeration Date	:	10/13/2014
Last Update Date	:	10/13/2014

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Directions to “THE WELLNESS COLLABORATIVE ” Practice Location

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