Organization Name: | LAKE GENEVA WELLNESS CLINIC LLC |
NPI Number: | 1003845181 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | ERIKA K FOUNTAIN (OWNER) |
Mailing Address: | 101 Broad St Suite 201 Lake Geneva |
State: | WI US |
Postal Code: | 531472000 |
Phone Number: | 2622487942 |
Fax Number: | |
NPI Enumeration Date: | 07/01/2006 |
NPI Last Update Date: | 09/27/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 811-057 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WI |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |