Provider Demographics
NPI:1528138278
Name:WELLNESS SUPPORTS, LLC
Entity type:Organization
Organization Name:WELLNESS SUPPORTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:919-782-8730
Mailing Address - Street 1:8390 SIX FORKS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3060
Mailing Address - Country:US
Mailing Address - Phone:919-782-8730
Mailing Address - Fax:919-782-8731
Practice Address - Street 1:8390 SIX FORKS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3060
Practice Address - Country:US
Practice Address - Phone:919-782-8730
Practice Address - Fax:919-782-8731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300341B251S00000X
NC6005366251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005366Medicaid
NC1528138278OtherBLUE CROSS BLUE SHEILD
NC8300341BMedicaid