Provider Demographics
NPI:1508695586
Name:CLINICAL CARE THERAPY & WELLNESS
Entity type:Organization
Organization Name:CLINICAL CARE THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVONCIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCASA, CCTP
Authorized Official - Phone:910-358-6742
Mailing Address - Street 1:231 NEW BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4736
Mailing Address - Country:US
Mailing Address - Phone:910-358-6742
Mailing Address - Fax:
Practice Address - Street 1:231 NEW BRIDGE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4736
Practice Address - Country:US
Practice Address - Phone:910-358-6742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty