Provider Demographics
NPI:1013512375
Name:K. ANTOINETTE WELLNESS LLC
Entity type:Organization
Organization Name:K. ANTOINETTE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TABB
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:240-723-2342
Mailing Address - Street 1:1928 WALMART WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2692
Mailing Address - Country:US
Mailing Address - Phone:240-723-2342
Mailing Address - Fax:
Practice Address - Street 1:1905 HUGUENOT RD STE 305
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4312
Practice Address - Country:US
Practice Address - Phone:240-723-2342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty