Provider Demographics
NPI:1124550587
Name:SAFE AND STABLE FAMILIES WELLNESS CENTER, P.C.
Entity Type:Organization
Organization Name:SAFE AND STABLE FAMILIES WELLNESS CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AGUSTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:229-412-8125
Mailing Address - Street 1:7825 MIDLOTHIAN TPKE STE 203
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-5247
Mailing Address - Country:US
Mailing Address - Phone:229-412-8125
Mailing Address - Fax:
Practice Address - Street 1:7825 MIDLOTHIAN TPKE STE 203
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-5247
Practice Address - Country:US
Practice Address - Phone:229-412-8125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701006356101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 102L00000X, 103K00000X
VA0717001358106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA601092813Medicaid