Healthcare Provider Details

I. General information

NPI: 1073250437
Provider Name (Legal Business Name): ENLIGHTENED WAYS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 BOULDER LN
BELOIT WI
53511-6709
US

IV. Provider business mailing address

2319 BOULDER LN
BELOIT WI
53511-6709
US

V. Phone/Fax

Practice location:
  • Phone: 608-346-8843
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMBERLY MIXON
Title or Position: OWNER
Credential:
Phone: 608-346-8843