Provider Demographics
NPI:1003414970
Name:PHYSIOLOGICAL HEALTH SANCTUARY LLC
Entity Type:Organization
Organization Name:PHYSIOLOGICAL HEALTH SANCTUARY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:YUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:414-350-7286
Mailing Address - Street 1:500 W SILVER SPRING DR STE K200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5052
Mailing Address - Country:US
Mailing Address - Phone:414-207-4415
Mailing Address - Fax:
Practice Address - Street 1:500 W SILVER SPRING DR STE K200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5052
Practice Address - Country:US
Practice Address - Phone:414-207-4415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health