Provider Demographics
NPI:1518221332
Name:AUNT GWEN'S PLACE, LLC
Entity Type:Organization
Organization Name:AUNT GWEN'S PLACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DASHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-944-4782
Mailing Address - Street 1:147 MILL RIDGE RD
Mailing Address - Street 2:SUITE 131
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-4341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 MILL RIDGE RD
Practice Address - Street 2:SUITE 131
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-4341
Practice Address - Country:US
Practice Address - Phone:434-944-4782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty