Provider Demographics
NPI:1881863082
Name:THE MENTAL HEALTH AND WELLNESS CLINIC, PLLC
Entity Type:Organization
Organization Name:THE MENTAL HEALTH AND WELLNESS CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTIN-WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:ANP/GNP
Authorized Official - Phone:336-391-5701
Mailing Address - Street 1:1978 WACCAMAW PATH
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9433
Mailing Address - Country:US
Mailing Address - Phone:336-391-5701
Mailing Address - Fax:
Practice Address - Street 1:1978 WACCAMAW PATH
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9433
Practice Address - Country:US
Practice Address - Phone:336-391-5701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102293251S00000X
NC900278261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251S00000XAgenciesCommunity/Behavioral Health