Healthcare Provider Details

I. General information

NPI: 1619651767
Provider Name (Legal Business Name): MY WELLNESS TEAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4916 N BEND RD
CINCINNATI OH
45211-2360
US

IV. Provider business mailing address

911 E 86TH ST SUITE 103
INDIANAPOLIS IN
46240
US

V. Phone/Fax

Practice location:
  • Phone: 317-750-1890
  • Fax:
Mailing address:
  • Phone: 812-267-2841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANNE ROBERTSON
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 812-267-2841