Provider Demographics
NPI:1700482601
Name:PURE HEALTH AND WELLNESS TREATMENT CENTER, PLLC
Entity Type:Organization
Organization Name:PURE HEALTH AND WELLNESS TREATMENT CENTER, PLLC
Other - Org Name:GROW THERAPEUTIC SERVICES, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CEYONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:443-842-4952
Mailing Address - Street 1:1320 CENTRAL PARK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4953
Mailing Address - Country:US
Mailing Address - Phone:703-881-6233
Mailing Address - Fax:
Practice Address - Street 1:1320 CENTRAL PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4953
Practice Address - Country:US
Practice Address - Phone:703-881-6233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty