MEDICARE: PALMETTO & VINE 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1790616837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO & VINE WELLNESS LLC

Provider Business Mailing Address
First Line	:	5805 FURLONG WAY
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-7316
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5805 FURLONG WAY
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-7316
Country	:	US
Telephone Number	:	513-202-3687
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BETHANY PUTNAM
Credential	:	LISW
Telephone Number	:	513-202-3687

Provider Enumeration Date	:	05/27/2026
Last Update Date	:	05/27/2026

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Directions to “PALMETTO & VINE WELLNESS LLC ” Practice Location

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