Provider Demographics
NPI:1356863617
Name:RIDE THE WAVE WELLNESS, INC.
Entity Type:Organization
Organization Name:RIDE THE WAVE WELLNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KNEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:630-383-7006
Mailing Address - Street 1:2405 TWIN FOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-6397
Mailing Address - Country:US
Mailing Address - Phone:773-655-1198
Mailing Address - Fax:630-383-7006
Practice Address - Street 1:123 W WASHINGTON ST STE 340
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8292
Practice Address - Country:US
Practice Address - Phone:630-383-7006
Practice Address - Fax:630-383-7006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-08
Last Update Date:2017-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.0004778101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1194092635OtherNPI 1