Healthcare Provider Details

I. General information

NPI: 1578382198
Provider Name (Legal Business Name): OPAL WATERS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 FALLS RD STE 688
GRAFTON WI
53024-2617
US

IV. Provider business mailing address

361 FALLS RD STE 688
GRAFTON WI
53024-2617
US

V. Phone/Fax

Practice location:
  • Phone: 608-668-4035
  • Fax:
Mailing address:
  • Phone: 608-668-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MISS GRACE KANZENBACH
Title or Position: OWNER
Credential: LCSW
Phone: 608-668-4035