Provider Demographics
| NPI: | 1124865654 |
|---|---|
| Name: | WELLNESS GROVE LLC |
| Entity type: | Organization |
| Organization Name: | WELLNESS GROVE LLC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF INFORMATION OFFICER |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | SHAUN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | SWIGER |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 330-915-2907 |
| Mailing Address - Street 1: | 4522 FULTON DR NW |
| Mailing Address - Street 2: | |
| Mailing Address - City: | CANTON |
| Mailing Address - State: | OH |
| Mailing Address - Zip Code: | 44718-2332 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 330-915-2907 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 4522 FULTON DR NW |
| Practice Address - Street 2: | |
| Practice Address - City: | CANTON |
| Practice Address - State: | OH |
| Practice Address - Zip Code: | 44718-2332 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 330-915-2907 |
| Practice Address - Fax: | 330-915-2958 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2024-07-11 |
| Last Update Date: | 2025-03-28 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | Group - Multi-Specialty |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 221700000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist | Group - Multi-Specialty | |
| No | 251S00000X | Agencies | Community/Behavioral Health | ||
| No | 261QC1500X | Ambulatory Health Care Facilities | Clinic/Center | Community Health | |
| No | 261QM0850X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | |
| No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
| No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| OH | 0085951 | Medicaid |
