Provider Demographics
NPI:1386678423
Name:AFFILIATED WELLNESS GROUP LLC
Entity type:Organization
Organization Name:AFFILIATED WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOELLE
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:OTTOSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:262-646-8288
Mailing Address - Street 1:N27W23960 PAUL RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6218
Mailing Address - Country:US
Mailing Address - Phone:262-646-8288
Mailing Address - Fax:262-646-8255
Practice Address - Street 1:N27W23960 PAUL RD STE 202
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6218
Practice Address - Country:US
Practice Address - Phone:262-646-8288
Practice Address - Fax:262-646-8255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========Medicaid
=========018OtherBLUE CROSSS
WI=========Medicaid