Provider Demographics
NPI:1063836484
Name:SEDALIA WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SEDALIA WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:573-268-4419
Mailing Address - Street 1:1721 S INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7535
Mailing Address - Country:US
Mailing Address - Phone:573-268-4419
Mailing Address - Fax:660-827-9879
Practice Address - Street 1:1721 S INGRAM AVE
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7535
Practice Address - Country:US
Practice Address - Phone:660-827-9875
Practice Address - Fax:660-827-9879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040337381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty