Healthcare Provider Details

I. General information

NPI: 1063096766
Provider Name (Legal Business Name): WISE WELLBEING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 05/29/2021
Certification Date: 05/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N 5TH AVE STE 230
ANN ARBOR MI
48104-5504
US

IV. Provider business mailing address

300 N 5TH AVE STE 230
ANN ARBOR MI
48104-5504
US

V. Phone/Fax

Practice location:
  • Phone: 734-646-2982
  • Fax:
Mailing address:
  • Phone: 734-646-0711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANNON TATUM
Title or Position: OWNER
Credential: LMSW
Phone: 734-646-0711