Provider Demographics
NPI:1679201784
Name:THERAVIV WELLNESS PLLC
Entity Type:Organization
Organization Name:THERAVIV WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALNER-CUTRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, PMH-C
Authorized Official - Phone:847-861-0602
Mailing Address - Street 1:402 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-8329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 SOMERSET DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN HILLS
Practice Address - State:IL
Practice Address - Zip Code:61548-8329
Practice Address - Country:US
Practice Address - Phone:847-861-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-09
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)