Provider Demographics
NPI:1649970757
Name:RESILIENT JOURNEY, LLC
Entity type:Organization
Organization Name:RESILIENT JOURNEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, APNP
Authorized Official - Phone:847-340-5785
Mailing Address - Street 1:2630 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-3216
Mailing Address - Country:US
Mailing Address - Phone:847-340-5785
Mailing Address - Fax:
Practice Address - Street 1:13500 WATERTOWN PLANK RD STE 102
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2222
Practice Address - Country:US
Practice Address - Phone:847-340-5785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-07
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty