Healthcare Provider Details

I. General information

NPI: 1447160155
Provider Name (Legal Business Name): SELAH WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 HIGHWAY 97 UNIT 1A
FOREST LAKE MN
55025-2687
US

IV. Provider business mailing address

501 MAIN ST
SANDSTONE MN
55072-4410
US

V. Phone/Fax

Practice location:
  • Phone: 320-372-2323
  • Fax: 833-651-2526
Mailing address:
  • Phone: 320-372-2323
  • Fax: 833-651-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: NAOMI KOENIG
Title or Position: CEO
Credential:
Phone: 320-372-2323