Provider Demographics
NPI:1659732592
Name:WELLSPACE COUNSELING & CONSULTING
Entity Type:Organization
Organization Name:WELLSPACE COUNSELING & CONSULTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS-HARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MTS, MSW, LCSW
Authorized Official - Phone:336-686-5838
Mailing Address - Street 1:105 E CENTER ST
Mailing Address - Street 2:SUITE B-11
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-2420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 E CENTER ST
Practice Address - Street 2:SUITE B-11
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-2420
Practice Address - Country:US
Practice Address - Phone:336-686-5838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0062731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6007342Medicaid
NCQ40586AMedicare UPIN