Provider Demographics
NPI:1366200222
Name:THE WELLNESS COLLABORATIVE, LLC
Entity type:Organization
Organization Name:THE WELLNESS COLLABORATIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:708-323-9290
Mailing Address - Street 1:11039 LONGBOAT KEY LN APT 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2753
Mailing Address - Country:US
Mailing Address - Phone:708-323-9290
Mailing Address - Fax:
Practice Address - Street 1:11039 LONGBOAT KEY LN APT 202
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2753
Practice Address - Country:US
Practice Address - Phone:708-323-9290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1558099655Other101YM0800X