Healthcare Provider Details

I. General information

NPI: 1396484366
Provider Name (Legal Business Name): AUTHENTIC WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2022
Last Update Date: 08/06/2023
Certification Date: 08/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54354 STATE HIGHWAY M203
HANCOCK MI
49930-9448
US

IV. Provider business mailing address

54354 STATE HIGHWAY M203
HANCOCK MI
49930-9448
US

V. Phone/Fax

Practice location:
  • Phone: 906-281-4806
  • Fax:
Mailing address:
  • Phone: 906-281-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KELLY NIILEKSELA
Title or Position: CO-OWNER
Credential:
Phone: 906-299-9355