Provider Demographics
NPI:1508409152
Name:OBSIDIAN COUNSELING AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:OBSIDIAN COUNSELING AND WELLNESS CENTER, LLC
Other - Org Name:OBSIDIAN COUNSELING AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER/LPC
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKUM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-453-3051
Mailing Address - Street 1:857 GEORGE WASHINGTON HWY N UNIT 6991
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23323-1362
Mailing Address - Country:US
Mailing Address - Phone:757-453-3051
Mailing Address - Fax:
Practice Address - Street 1:6387 CENTER DR STE 19
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4109
Practice Address - Country:US
Practice Address - Phone:757-453-3051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-25
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)