Healthcare Provider Details

I. General information

NPI: 1124709308
Provider Name (Legal Business Name): WELLNESS HAVEN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7285 LAKESHORE RD
LEXINGTON MI
48450-9772
US

IV. Provider business mailing address

5124 BIRCH AVE
LEXINGTON MI
48450-9261
US

V. Phone/Fax

Practice location:
  • Phone: 810-300-9465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: KORTNEY BALL
Title or Position: OWNER/PROFESSIONAL COUNSELOR
Credential: L.P.C., S.C.L.
Phone: 810-300-9465