Healthcare Provider Details

I. General information

NPI: 1548041924
Provider Name (Legal Business Name): WISCONSIN WELLNESS MH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5643 W WATERFORD LN
APPLETON WI
54913-8438
US

IV. Provider business mailing address

5643 W WATERFORD LN
APPLETON WI
54913-8438
US

V. Phone/Fax

Practice location:
  • Phone: 920-404-2100
  • Fax:
Mailing address:
  • Phone: 920-404-2100
  • Fax:

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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: RYAN JOSEPH ROHDE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 715-281-0612