Healthcare Provider Details

I. General information

NPI: 1407593619
Provider Name (Legal Business Name): MERAKI THERAPY & WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 11/13/2022
Certification Date: 11/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 MAIN ST STE 120
GREEN BAY WI
54302-1337
US

IV. Provider business mailing address

1270 MAIN ST STE 120
GREEN BAY WI
54302-1337
US

V. Phone/Fax

Practice location:
  • Phone: 920-378-3575
  • Fax:
Mailing address:
  • Phone: 920-288-2846
  • Fax: 920-770-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE WAACK
Title or Position: CO-OWNER
Credential: MAC, LPC, CSAC
Phone: 920-288-2846