Provider Demographics
NPI:1740805019
Name:ESSENTIAL WELLNESS COUNSELING PLLC
Entity Type:Organization
Organization Name:ESSENTIAL WELLNESS COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TYEEKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCAS
Authorized Official - Phone:980-236-1704
Mailing Address - Street 1:4350 MAIN ST STE 213
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-7448
Mailing Address - Country:US
Mailing Address - Phone:980-236-1704
Mailing Address - Fax:980-206-0709
Practice Address - Street 1:4350 MAIN ST STE 213
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:NC
Practice Address - Zip Code:28075-7448
Practice Address - Country:US
Practice Address - Phone:980-236-1704
Practice Address - Fax:980-206-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083153563Medicaid