NPIMap

Organization Active NPI

Impact Wellness Center LLC

  • Mental Health Counselor
  • North Chesterfield, VA
National Provider Identifier
1205509205
Registry record updated Jul 27, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
Legal business name
IMPACT WELLNESS CENTER LLC
Practice address
2700 Galena Ave
North Chesterfield, VA 23237-4638
Phone
(702) 754-9136
NPI assigned
Jul 27, 2021
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 27, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Phillip C StaffordNPI 1376083220
Title
Ceo
Phone
(702) 754-9063

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X Primary
Cognitive & Behavioral PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TB0200X
Counseling PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TC1900X
Intellectual & Developmental Disabilities PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TM1800X

Addresses

Primary practice location

2700 Galena Ave
North Chesterfield, VA 23237-4638

Mailing address

2700 Galena Ave
North Chesterfield, VA 23237-4638
Phone (702) 754-9136

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1627344000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1627344000000",
    "number": "1205509205",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2700 GALENA AVE",
            "city": "NORTH CHESTERFIELD",
            "state": "VA",
            "postal_code": "232374638",
            "telephone_number": "702-754-9136"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2700 GALENA AVE",
            "city": "NORTH CHESTERFIELD",
            "state": "VA",
            "postal_code": "232374638",
            "telephone_number": "702-754-9136"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPACT WELLNESS CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-07-27",
        "last_updated": "2021-07-27",
        "certification_date": "2021-07-27",
        "status": "A",
        "authorized_official_last_name": "STAFFORD",
        "authorized_official_first_name": "PHILLIP",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "702-754-9063"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "103TB0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC1900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TM1800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Intellectual & Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in North Chesterfield, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 27, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.