Provider Demographics
NPI:1083252860
Name:TGL WELLNESS
Entity Type:Organization
Organization Name:TGL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:LOOMIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:414-218-6958
Mailing Address - Street 1:2367 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-2917
Mailing Address - Country:US
Mailing Address - Phone:414-218-6958
Mailing Address - Fax:
Practice Address - Street 1:1750 N CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5037
Practice Address - Country:US
Practice Address - Phone:414-218-6958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)