Provider Demographics
NPI:1134625007
Name:MIDWEST WELLNESS LLC
Entity type:Organization
Organization Name:MIDWEST WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:269-262-1815
Mailing Address - Street 1:20 N 2ND ST STE 103
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2259
Mailing Address - Country:US
Mailing Address - Phone:269-262-1815
Mailing Address - Fax:
Practice Address - Street 1:24 N SAINT JOSEPH AVE STE C2
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-262-1815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-01
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013717101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty