Provider Demographics
NPI:1558015305
Name:ELEMENTAL HEALTH CLINIC PLLC
Entity type:Organization
Organization Name:ELEMENTAL HEALTH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAVAH
Authorized Official - Middle Name:ISABEL
Authorized Official - Last Name:HENZLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCAS
Authorized Official - Phone:910-599-4017
Mailing Address - Street 1:5030 RANDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-2829
Mailing Address - Country:US
Mailing Address - Phone:910-240-4757
Mailing Address - Fax:
Practice Address - Street 1:5030 RANDALL PKWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2829
Practice Address - Country:US
Practice Address - Phone:910-240-4757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care