Provider Demographics
NPI:1588158679
Name:HOPE ROAD WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:HOPE ROAD WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:715-491-5365
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:FREDERIC
Mailing Address - State:WI
Mailing Address - Zip Code:54837-0383
Mailing Address - Country:US
Mailing Address - Phone:715-869-6484
Mailing Address - Fax:800-684-2131
Practice Address - Street 1:107 HOPE ROAD WEST
Practice Address - Street 2:
Practice Address - City:FREDERIC
Practice Address - State:WI
Practice Address - Zip Code:54837-0383
Practice Address - Country:US
Practice Address - Phone:715-491-5365
Practice Address - Fax:800-684-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1689004426Medicaid