1013413657 NPI number — LIVING WELL MENTAL HEALTH CLINIC LLC

Table of content: (NPI 1013413657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013413657 NPI number — LIVING WELL MENTAL HEALTH CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WELL MENTAL HEALTH CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013413657
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 65
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWEN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54460-0065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-229-0330
Provider Business Mailing Address Fax Number:
715-229-0331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 N CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWEN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54460
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-313-4748
Provider Business Practice Location Address Fax Number:
715-229-0331
Provider Enumeration Date:
04/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GREUB
Authorized Official First Name:
BECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL PSYCHOLOGIST
Authorized Official Telephone Number:
715-313-4748

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1548793235 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720477182 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: K400340967 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184002560 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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