Organization
IMPACT WELLNESS CENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PHILLIP C STAFFORD (CEO)
(702) 754-9063
Entity
Organization
Contact information
Practice address
2700 GALENA AVE, NORTH CHESTERFIELD, VA 23237-4638
(702) 754-9136
Mailing address
2700 GALENA AVE, NORTH CHESTERFIELD, VA 23237-4638
(702) 754-9136
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
—
—
103TB0200X
Cognitive & Behavioral Psychologist
—
—
103TC1900X
Counseling Psychologist
—
—
103TM1800X
Intellectual & Developmental Disabilities Psychologist
—
—
Other
Enumeration date
07/27/2021
Last updated
07/27/2021
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