Healthcare Provider Details

I. General information

NPI: 1609480482
Provider Name (Legal Business Name): GROUNDED LIVING ECOTHERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROOSEVELT DR
DRESSER WI
54009-9065
US

IV. Provider business mailing address

401 ROOSEVELT DR
DRESSER WI
54009-9065
US

V. Phone/Fax

Practice location:
  • Phone: 715-494-0004
  • Fax:
Mailing address:
  • Phone: 715-494-0004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: SHEENA MALM
Title or Position: OWNER
Credential: LPC
Phone: 715-494-0004