Healthcare Provider Details

I. General information

NPI: 1649970757
Provider Name (Legal Business Name): RESILIENT JOURNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 WATERTOWN PLANK RD STE 102
ELM GROVE WI
53122-2222
US

IV. Provider business mailing address

2630 9TH AVE
SOUTH MILWAUKEE WI
53172-3216
US

V. Phone/Fax

Practice location:
  • Phone: 847-340-5785
  • Fax:
Mailing address:
  • Phone: 847-340-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONALD ROTH
Title or Position: OWNER
Credential: PSYD, APNP
Phone: 847-340-5785