Provider Demographics
NPI:1083178693
Name:RESTORE WELLNESS COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:RESTORE WELLNESS COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHODENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MESADIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-224-1054
Mailing Address - Street 1:4180 SAN MARINO BLVD APT 208
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-8626
Mailing Address - Country:US
Mailing Address - Phone:772-224-1054
Mailing Address - Fax:
Practice Address - Street 1:11440 OKEECHOBEE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-8726
Practice Address - Country:US
Practice Address - Phone:561-316-7517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty