Provider Demographics
NPI:1013413657
Name:LIVING WELL MENTAL HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:LIVING WELL MENTAL HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-229-0330
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:OWEN
Mailing Address - State:WI
Mailing Address - Zip Code:54460-0065
Mailing Address - Country:US
Mailing Address - Phone:715-229-0330
Mailing Address - Fax:715-229-0331
Practice Address - Street 1:112 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OWEN
Practice Address - State:WI
Practice Address - Zip Code:54460
Practice Address - Country:US
Practice Address - Phone:715-229-0330
Practice Address - Fax:715-229-0331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720477182Medicaid
WI1184002560Medicaid
WI1548793235Medicaid
WIK400340967Medicaid