Provider Demographics
NPI:1598150732
Name:SEAGLASS COUNSELING & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SEAGLASS COUNSELING & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:NACKOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:866-832-6260
Mailing Address - Street 1:986 LEONARDVILLE RD
Mailing Address - Street 2:FLOOR 1
Mailing Address - City:ATLANTIC HIGHLANDS
Mailing Address - State:NJ
Mailing Address - Zip Code:07716-2713
Mailing Address - Country:US
Mailing Address - Phone:866-832-6260
Mailing Address - Fax:
Practice Address - Street 1:986 LEONARDVILLE RD
Practice Address - Street 2:FLOOR 1
Practice Address - City:ATLANTIC HIGHLANDS
Practice Address - State:NJ
Practice Address - Zip Code:07716-2713
Practice Address - Country:US
Practice Address - Phone:866-832-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC054752001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC05475200OtherLCSW LICENSE
NJ44SC05487600OtherLCSW LICENSE