Provider Demographics
NPI:1386133809
Name:WOW THERAPY
Entity type:Organization
Organization Name:WOW THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YUVONE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:810-300-6614
Mailing Address - Street 1:4043 VIOLET AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-3532
Mailing Address - Country:US
Mailing Address - Phone:810-300-6614
Mailing Address - Fax:
Practice Address - Street 1:805 SUPERIOR ST STE A
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3771
Practice Address - Country:US
Practice Address - Phone:810-300-6614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty