Provider Demographics
NPI:1710482666
Name:JOURNEY2WELLNESS LLC
Entity Type:Organization
Organization Name:JOURNEY2WELLNESS LLC
Other - Org Name:STACEY BRUCE LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:573-718-8897
Mailing Address - Street 1:5205 CRABAPPLE LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-8524
Mailing Address - Country:US
Mailing Address - Phone:573-718-8897
Mailing Address - Fax:
Practice Address - Street 1:1910 GREENWOOD DR STE D
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2430
Practice Address - Country:US
Practice Address - Phone:573-718-8897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010001438251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health