Provider Demographics
NPI:1255052866
Name:RUBY WAVES OF WELLNESS
Entity type:Organization
Organization Name:RUBY WAVES OF WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:DORTHEA
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:765-761-3997
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:IL
Mailing Address - Zip Code:61859-0374
Mailing Address - Country:US
Mailing Address - Phone:217-274-2363
Mailing Address - Fax:
Practice Address - Street 1:105 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:IL
Practice Address - Zip Code:61859-8808
Practice Address - Country:US
Practice Address - Phone:217-274-2363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1740650530Medicaid
IL149019804OtherLCSW