Provider Demographics
NPI:1265132088
Name:NOURISH WELLNESS LLC
Entity type:Organization
Organization Name:NOURISH WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:OVIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:504-491-8963
Mailing Address - Street 1:163 PARKHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-7211
Mailing Address - Country:US
Mailing Address - Phone:504-491-8963
Mailing Address - Fax:
Practice Address - Street 1:820 LAKESHORE VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-6605
Practice Address - Country:US
Practice Address - Phone:504-491-8963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health