Provider Demographics
NPI:1477135838
Name:EMBRACE WELLNESS COASTAL GROUP, LLC
Entity Type:Organization
Organization Name:EMBRACE WELLNESS COASTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HILLARY
Authorized Official - Middle Name:ASTHON
Authorized Official - Last Name:FAULK VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPA, HSP-PA
Authorized Official - Phone:910-232-6127
Mailing Address - Street 1:3208 OLEANDER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-0800
Mailing Address - Country:US
Mailing Address - Phone:910-746-8717
Mailing Address - Fax:
Practice Address - Street 1:3208 OLEANDER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0800
Practice Address - Country:US
Practice Address - Phone:910-746-8717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1871999102OtherNPPES
1902279839OtherNPPES