Basic Information
| Provider Information | |||||||||
| NPI: | 1083079115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL WELLNESS GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9990 COCONUT RD | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341358488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393901161 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9990 COCONUT RD | ||||||||
| Address2: | |||||||||
| City: | ESTERO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341358488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393901161 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2015 | ||||||||
| LastUpdateDate: | 08/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | RAE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 2393901161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.