Provider Demographics
NPI:1467071985
Name:HYACINTH WELLNESS, LLC
Entity Type:Organization
Organization Name:HYACINTH WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:202-906-0334
Mailing Address - Street 1:2303 IRVING ST SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-2717
Mailing Address - Country:US
Mailing Address - Phone:202-906-0334
Mailing Address - Fax:
Practice Address - Street 1:1224 M ST NW STE 200
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-5225
Practice Address - Country:US
Practice Address - Phone:202-850-0641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1659861458Medicaid