Healthcare Provider Details

I. General information

NPI: 1376214759
Provider Name (Legal Business Name): THE WELLIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 BELDEN VILLAGE ST NW STE 604
CANTON OH
44718-3672
US

IV. Provider business mailing address

3427 27TH ST NW
CANTON OH
44708-1707
US

V. Phone/Fax

Practice location:
  • Phone: 419-581-9835
  • Fax:
Mailing address:
  • Phone: 419-581-9835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. KATIE GAMBY
Title or Position: CEO
Credential: LPCC
Phone: 419-581-9835