Provider Demographics
NPI:1316429814
Name:WATERSHED WELLNESS LLC
Entity type:Organization
Organization Name:WATERSHED WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHTON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOFGREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-831-5700
Mailing Address - Street 1:579 N 1ST BANK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-8102
Mailing Address - Country:US
Mailing Address - Phone:737-831-5700
Mailing Address - Fax:847-907-9994
Practice Address - Street 1:579 N 1ST BANK DR STE 150
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-8102
Practice Address - Country:US
Practice Address - Phone:737-831-5700
Practice Address - Fax:847-907-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071009227103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty