Provider Demographics
NPI:1124730023
Name:EMBODIED-WELLLBEING
Entity type:Organization
Organization Name:EMBODIED-WELLLBEING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:NEILITZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-521-8940
Mailing Address - Street 1:2501 JENNY LN APT 8
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-5039
Mailing Address - Country:US
Mailing Address - Phone:920-521-8940
Mailing Address - Fax:
Practice Address - Street 1:2501 JENNY LANE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302
Practice Address - Country:US
Practice Address - Phone:920-212-7523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty