Provider Demographics
NPI:1073377156
Name:SPREADING YOUR WINGS LLC
Entity Type:Organization
Organization Name:SPREADING YOUR WINGS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAMRYN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:727-477-0864
Mailing Address - Street 1:3980 TAMPA RD STE 202
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3223
Mailing Address - Country:US
Mailing Address - Phone:727-477-0864
Mailing Address - Fax:
Practice Address - Street 1:3980 TAMPA RD STE 202
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3223
Practice Address - Country:US
Practice Address - Phone:727-477-0864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center