Provider Demographics
NPI:1417633553
Name:ABUNDANCE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:ABUNDANCE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:551-275-5674
Mailing Address - Street 1:13732 THURSTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2637
Mailing Address - Country:US
Mailing Address - Phone:551-275-5674
Mailing Address - Fax:
Practice Address - Street 1:13732 THURSTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-2637
Practice Address - Country:US
Practice Address - Phone:551-275-5674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty