Provider Demographics
NPI:1114297314
Name:FOUR BRANCHES THERAPY & WELLNESS, LLC
Entity Type:Organization
Organization Name:FOUR BRANCHES THERAPY & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:STUEVER
Authorized Official - Suffix:
Authorized Official - Credentials:LCMFT
Authorized Official - Phone:316-648-8886
Mailing Address - Street 1:11828 W CENTRAL AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-5178
Mailing Address - Country:US
Mailing Address - Phone:316-648-8886
Mailing Address - Fax:
Practice Address - Street 1:11828 W CENTRAL AVE STE 104
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-5178
Practice Address - Country:US
Practice Address - Phone:316-648-8886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-04
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLCMFT 756251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200671720BMedicaid