Provider Demographics
NPI:1104427806
Name:EMERALD GROVE WELLNESS LLC
Entity type:Organization
Organization Name:EMERALD GROVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GANTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:724-766-3825
Mailing Address - Street 1:214 BRICKYARD RD
Mailing Address - Street 2:
Mailing Address - City:MARS
Mailing Address - State:PA
Mailing Address - Zip Code:16046-3006
Mailing Address - Country:US
Mailing Address - Phone:724-766-3825
Mailing Address - Fax:334-344-7725
Practice Address - Street 1:214 BRICKYARD RD
Practice Address - Street 2:
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-3006
Practice Address - Country:US
Practice Address - Phone:724-766-3825
Practice Address - Fax:334-344-7725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty