1740968825 NPI number — CHERRY BLOSSOM HEALING, LLC

Table of content: (NPI 1740968825)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740968825 NPI number — CHERRY BLOSSOM HEALING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHERRY BLOSSOM HEALING, 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:
1740968825
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1314 MAYER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENASHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54952-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-213-8137
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-3075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-725-1230
Provider Business Practice Location Address Fax Number:
920-215-6164
Provider Enumeration Date:
07/07/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
LISA
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
PSYCHOTHERAPIST
Authorized Official Telephone Number:
920-213-8137

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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