Provider Demographics
NPI:1881228559
Name:BELOVED WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:BELOVED WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRITCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LCSW, CSAC
Authorized Official - Phone:262-496-8897
Mailing Address - Street 1:3535 30TH AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1632
Mailing Address - Country:US
Mailing Address - Phone:262-496-8897
Mailing Address - Fax:
Practice Address - Street 1:3535 30TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1632
Practice Address - Country:US
Practice Address - Phone:262-496-8897
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-02
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356605323Medicaid