Provider Demographics
NPI:1396149829
Name:THE WELLNESS COLLABORATIVE
Entity type:Organization
Organization Name:THE WELLNESS COLLABORATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:757-412-7753
Mailing Address - Street 1:PO BOX 6892
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0892
Mailing Address - Country:US
Mailing Address - Phone:757-412-7753
Mailing Address - Fax:757-301-6920
Practice Address - Street 1:1664 CHESTWOOD DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-7064
Practice Address - Country:US
Practice Address - Phone:757-412-7753
Practice Address - Fax:757-301-6920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001246251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health