Provider Demographics
NPI:1043830425
Name:GODDESS HEALTH & WELLNESS, LLC
Entity Type:Organization
Organization Name:GODDESS HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER/MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOMEKA
Authorized Official - Middle Name:CONSWELLO
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-848-7104
Mailing Address - Street 1:PO BOX 4223
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33338-4223
Mailing Address - Country:US
Mailing Address - Phone:754-300-7591
Mailing Address - Fax:954-206-0496
Practice Address - Street 1:5420 HOLLYWOOD BLVD APT 111
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6481
Practice Address - Country:US
Practice Address - Phone:754-300-7591
Practice Address - Fax:954-206-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty