Provider Demographics
NPI:1851127021
Name:PRIME WELLNESS
Entity type:Organization
Organization Name:PRIME WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONTIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:419-508-9566
Mailing Address - Street 1:2727 2ND AVE STE 131
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2660
Mailing Address - Country:US
Mailing Address - Phone:419-508-9566
Mailing Address - Fax:
Practice Address - Street 1:2727 2ND AVE STE 131
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2660
Practice Address - Country:US
Practice Address - Phone:419-508-9566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty