Provider Demographics
NPI:1376274514
Name:WISHING WELL MENTAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:WISHING WELL MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANSHEREES
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-514-3248
Mailing Address - Street 1:707 GITTINGS ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-6101
Mailing Address - Country:US
Mailing Address - Phone:757-514-3248
Mailing Address - Fax:757-809-5387
Practice Address - Street 1:707 GITTINGS ST STE 120
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-6101
Practice Address - Country:US
Practice Address - Phone:757-514-3248
Practice Address - Fax:757-809-5387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health