Healthcare Provider Details

I. General information

NPI: 1356255707
Provider Name (Legal Business Name): INTENTIONAL WELLNESS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 INDIANA AVE
LA PORTE IN
46350-6005
US

IV. Provider business mailing address

1905 INDIANA AVE
LA PORTE IN
46350-6005
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-0358
  • Fax:
Mailing address:
  • Phone: 574-387-0358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: STEPHANIE L METCALF
Title or Position: OWNER
Credential:
Phone: 574-387-0358