Provider Demographics
NPI:1962950865
Name:MAPLE TREE WELLNESS, LLC
Entity type:Organization
Organization Name:MAPLE TREE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-466-6411
Mailing Address - Street 1:2920 EAST AVE S STE 101
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-8282
Mailing Address - Country:US
Mailing Address - Phone:608-466-6411
Mailing Address - Fax:608-572-7737
Practice Address - Street 1:205 5TH AVE S STE 306
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4059
Practice Address - Country:US
Practice Address - Phone:608-466-6411
Practice Address - Fax:608-572-7737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8384-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty