Provider Demographics
NPI:1396484366
Name:AUTHENTIC WELLNESS, LLC
Entity type:Organization
Organization Name:AUTHENTIC WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIILEKSELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-299-9355
Mailing Address - Street 1:54354 STATE HIGHWAY M203
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-9448
Mailing Address - Country:US
Mailing Address - Phone:906-281-4806
Mailing Address - Fax:
Practice Address - Street 1:54354 STATE HIGHWAY M203
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-9448
Practice Address - Country:US
Practice Address - Phone:906-281-4806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-30
Last Update Date:2023-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty