Provider Demographics
NPI:1235378332
Name:NEOGENISIS HOLISTIC HEALTH & WELLNESS, LLC
Entity Type:Organization
Organization Name:NEOGENISIS HOLISTIC HEALTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LILJA-HOLBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:503-380-5222
Mailing Address - Street 1:2045 SE WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222
Mailing Address - Country:US
Mailing Address - Phone:503-380-5222
Mailing Address - Fax:
Practice Address - Street 1:2045 SE WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222
Practice Address - Country:US
Practice Address - Phone:503-380-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10827225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10827OtherLMT LICENSE