Provider Demographics
NPI:1306569629
Name:WELLNESS WEST LLC
Entity type:Organization
Organization Name:WELLNESS WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VANN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:262-259-4100
Mailing Address - Street 1:2428 N GRANDVIEW BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6906
Mailing Address - Country:US
Mailing Address - Phone:262-259-4100
Mailing Address - Fax:
Practice Address - Street 1:2428 N GRANDVIEW BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-6906
Practice Address - Country:US
Practice Address - Phone:262-259-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)