Provider Demographics
NPI:1891267761
Name:OLD TOWNE WELLNESS, LLC
Entity Type:Organization
Organization Name:OLD TOWNE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JERI
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-938-8884
Mailing Address - Street 1:7489 RIGHT FLANK RD STE 330
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-3845
Mailing Address - Country:US
Mailing Address - Phone:804-938-8884
Mailing Address - Fax:804-789-8881
Practice Address - Street 1:7489 RIGHT FLANK RD STE 330
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3845
Practice Address - Country:US
Practice Address - Phone:804-938-8884
Practice Address - Fax:804-789-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty