Provider Demographics
NPI:1053879775
Name:INTEGRATED WELLNESS AND MENTAL HEALTH, LLC
Entity type:Organization
Organization Name:INTEGRATED WELLNESS AND MENTAL HEALTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-469-0313
Mailing Address - Street 1:401 N 8TH ST UNIT 58
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-7148
Mailing Address - Country:US
Mailing Address - Phone:479-469-0313
Mailing Address - Fax:497-769-3000
Practice Address - Street 1:700 N 40TH ST STE B
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0633
Practice Address - Country:US
Practice Address - Phone:479-318-2828
Practice Address - Fax:479-318-2683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR203270758Medicaid