Provider Demographics
NPI:1053671321
Name:INTEGRATED WELLNESS COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:INTEGRATED WELLNESS COUNSELING SERVICES, LLC
Other - Org Name:DEVONA M. STALNAKER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEVONA
Authorized Official - Middle Name:M
Authorized Official - Last Name:STALNAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-318-1994
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1359
Mailing Address - Country:US
Mailing Address - Phone:678-318-1994
Mailing Address - Fax:678-377-6080
Practice Address - Street 1:195 W PIKE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4966
Practice Address - Country:US
Practice Address - Phone:678-318-1994
Practice Address - Fax:678-377-6080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004683251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
12183939OtherCAQH