Provider Demographics
NPI:1780462473
Name:INTERCONNECTION WELLNESS LLC
Entity type:Organization
Organization Name:INTERCONNECTION WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTAL
Authorized Official - Middle Name:ALEXIS
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:470-369-0957
Mailing Address - Street 1:113 S PERRY ST
Mailing Address - Street 2:SUITE 206 #9320
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4811
Mailing Address - Country:US
Mailing Address - Phone:470-369-0957
Mailing Address - Fax:
Practice Address - Street 1:113 S PERRY ST STE 206
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4811
Practice Address - Country:US
Practice Address - Phone:470-326-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-15
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty