Provider Demographics
NPI:1104520840
Name:HARBOR SHORE WELLNESS PLLC
Entity type:Organization
Organization Name:HARBOR SHORE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROCHA
Authorized Official - Suffix:II
Authorized Official - Credentials:LCSW
Authorized Official - Phone:262-358-3592
Mailing Address - Street 1:8114 41ST AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-4544
Mailing Address - Country:US
Mailing Address - Phone:262-358-3592
Mailing Address - Fax:
Practice Address - Street 1:8114 41ST AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142
Practice Address - Country:US
Practice Address - Phone:262-358-3592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty