Provider Demographics
NPI:1255026746
Name:SEASIDE WELLNESS, LLC
Entity type:Organization
Organization Name:SEASIDE WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-813-7894
Mailing Address - Street 1:402 OLD LANDING RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23692-4316
Mailing Address - Country:US
Mailing Address - Phone:757-813-7894
Mailing Address - Fax:
Practice Address - Street 1:501 VILLAGE AVE STE 204
Practice Address - Street 2:
Practice Address - City:YORKTOWN
Practice Address - State:VA
Practice Address - Zip Code:23693-5657
Practice Address - Country:US
Practice Address - Phone:757-813-7894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty