Provider Demographics
NPI:1356643563
Name:LIVE GENTLE WELLNESS, LLC
Entity Type:Organization
Organization Name:LIVE GENTLE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW, PI-P
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PI-P
Authorized Official - Phone:605-759-6080
Mailing Address - Street 1:2752 E WORCESTER PL
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-4826
Mailing Address - Country:US
Mailing Address - Phone:605-759-6080
Mailing Address - Fax:
Practice Address - Street 1:2752 E WORCESTER PL
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-4826
Practice Address - Country:US
Practice Address - Phone:605-759-6080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health