Provider Demographics
NPI:1639613912
Name:WHOLE CHILD WELLNESS, LLC
Entity Type:Organization
Organization Name:WHOLE CHILD WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MESSNER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:605-718-1181
Mailing Address - Street 1:2340 DEADWOOD AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0356
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2340 DEADWOOD AVE
Practice Address - Street 2:SUITE K
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-0356
Practice Address - Country:US
Practice Address - Phone:605-718-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0857251E00000X, 252Y00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251E00000XAgenciesHome Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center