Provider Demographics
NPI:1649965419
Name:LIVWELL THERAPY & WELLNESS
Entity type:Organization
Organization Name:LIVWELL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-213-4114
Mailing Address - Street 1:7501 W 101ST ST APT 114
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2519
Mailing Address - Country:US
Mailing Address - Phone:952-213-4114
Mailing Address - Fax:952-213-4117
Practice Address - Street 1:213 74TH WAY N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-3001
Practice Address - Country:US
Practice Address - Phone:612-456-1036
Practice Address - Fax:952-213-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty