MEDICARE: WELLNESS JOURNEY, 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)

General Provider Information

NPI Number	:	1538775200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS JOURNEY, LLC

Provider Business Mailing Address
First Line	:	14525 WOODLEIGH DR
Second Line	:
City	:	CHESTER
State	:	VA
Zip	:	23831-6587
Country	:	US
Telephone Number	:	804-931-1182
Fax Number	:	804-655-6170

Provider Business Practice Location Address
First Line	:	3600 HEMLOCK AVE
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1328
Country	:	US
Telephone Number	:	804-931-1182
Fax Number	:	804-655-6170

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. CYNTHIA L MINTO
Credential	:	PHD, LCP
Telephone Number	:	804-931-1182

Provider Enumeration Date	:	09/18/2020
Last Update Date	:	09/18/2020

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