Healthcare Provider Details

I. General information

NPI: 1124865654
Provider Name (Legal Business Name): WELLNESS GROVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4522 FULTON DR NW
CANTON OH
44718-2332
US

IV. Provider business mailing address

4522 FULTON DR NW
CANTON OH
44718-2332
US

V. Phone/Fax

Practice location:
  • Phone: 330-915-2907
  • Fax: 330-915-2958
Mailing address:
  • Phone: 330-915-2907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHAUN SWIGER
Title or Position: CHIEF INFORMATION OFFICER
Credential:
Phone: 330-915-2907