Provider Demographics
NPI:1609480482
Name:GROUNDED LIVING ECOTHERAPY SERVICES LLC
Entity Type:Organization
Organization Name:GROUNDED LIVING ECOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:715-494-0004
Mailing Address - Street 1:401 ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:DRESSER
Mailing Address - State:WI
Mailing Address - Zip Code:54009-9065
Mailing Address - Country:US
Mailing Address - Phone:715-494-0004
Mailing Address - Fax:
Practice Address - Street 1:401 ROOSEVELT DR
Practice Address - Street 2:
Practice Address - City:DRESSER
Practice Address - State:WI
Practice Address - Zip Code:54009-9065
Practice Address - Country:US
Practice Address - Phone:715-494-0004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty