Provider Demographics
NPI:1548986052
Name:PSYCHOLOGICAL WELLNESS GROUP, LLC
Entity type:Organization
Organization Name:PSYCHOLOGICAL WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SYLWIA
Authorized Official - Middle Name:PATRYCJA
Authorized Official - Last Name:HODOREK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-759-7332
Mailing Address - Street 1:1311 N PAUL RUSSELL RD STE B102
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-4880
Mailing Address - Country:US
Mailing Address - Phone:850-759-7332
Mailing Address - Fax:
Practice Address - Street 1:1311 N PAUL RUSSELL RD STE B102
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4880
Practice Address - Country:US
Practice Address - Phone:850-759-7332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty