Provider Demographics
NPI:1689122012
Name:MOMENTUM COUNSELING AND WELLNESS LLC
Entity Type:Organization
Organization Name:MOMENTUM COUNSELING AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRIE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:BOGAZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-437-2599
Mailing Address - Street 1:431 WALTON PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-437-2599
Mailing Address - Fax:
Practice Address - Street 1:431 WALTON PARK ROAD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-437-2599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040069871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty