Provider Demographics
NPI:1124371448
Name:WACCAMAWS HEALTH AND WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:WACCAMAWS HEALTH AND WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PSYCHOTHERAPIST
Authorized Official - Prefix:PROF
Authorized Official - First Name:LAKEYSA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CAC-P, MSW, LISW-CP
Authorized Official - Phone:843-279-0172
Mailing Address - Street 1:314A LAUREL ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-5157
Mailing Address - Country:US
Mailing Address - Phone:843-279-0172
Mailing Address - Fax:843-438-5386
Practice Address - Street 1:314A LAUREL ST
Practice Address - Street 2:SUITE 205
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-5157
Practice Address - Country:US
Practice Address - Phone:843-279-0172
Practice Address - Fax:843-438-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC73341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty