Provider Demographics
NPI:1417718230
Name:DE NOVO WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:DE NOVO WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:UNION
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:719-400-8836
Mailing Address - Street 1:1005 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-3035
Mailing Address - Country:US
Mailing Address - Phone:719-400-8836
Mailing Address - Fax:
Practice Address - Street 1:1005 N 10TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-3035
Practice Address - Country:US
Practice Address - Phone:719-400-8836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty