Healthcare Provider Details

I. General information

NPI: 1265365530
Provider Name (Legal Business Name): REGENERATION WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 E BENNETT ST STE 104
SPRINGFIELD MO
65804-1400
US

IV. Provider business mailing address

723 N OAK GROVE AVE
SPRINGFIELD MO
65802-2367
US

V. Phone/Fax

Practice location:
  • Phone: 417-231-5723
  • Fax:
Mailing address:
  • Phone: 417-231-5723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LISA GRIM
Title or Position: OWNER
Credential: LPC
Phone: 417-231-5723