Provider Demographics
NPI:1811629926
Name:UPSTATE MENTAL WELLNESS, LLC
Entity Type:Organization
Organization Name:UPSTATE MENTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HEUVELMAN-HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-230-0476
Mailing Address - Street 1:419 SE MAIN ST STE 203A-2
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2673
Mailing Address - Country:US
Mailing Address - Phone:678-230-0476
Mailing Address - Fax:833-905-4587
Practice Address - Street 1:419 SE MAIN ST STE 203A-2
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2673
Practice Address - Country:US
Practice Address - Phone:678-230-0476
Practice Address - Fax:833-905-4587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health