Provider Demographics
NPI:1316208069
Name:WELLNESS PLACE LLC
Entity Type:Organization
Organization Name:WELLNESS PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:KRISTIN
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:270-601-4235
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:KUTTAWA
Mailing Address - State:KY
Mailing Address - Zip Code:42055-0250
Mailing Address - Country:US
Mailing Address - Phone:270-601-4235
Mailing Address - Fax:270-365-4438
Practice Address - Street 1:68 CEDAR ST.
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055
Practice Address - Country:US
Practice Address - Phone:270-601-1575
Practice Address - Fax:270-350-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1313103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100299330Medicaid