Healthcare Provider Details

I. General information

NPI: 1447628367
Provider Name (Legal Business Name): CALLA WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1569
US

IV. Provider business mailing address

164 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1569
US

V. Phone/Fax

Practice location:
  • Phone: 765-276-8642
  • Fax:
Mailing address:
  • Phone: 765-276-8642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34004717A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number890736
License Number StateIN

VIII. Authorized Official

Name: LISA B WERTH
Title or Position: CO-OWNER
Credential: LCSW
Phone: 765-427-5758