Healthcare Provider Details

I. General information

NPI: 1417359324
Provider Name (Legal Business Name): HARBOR HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 LARSEN RD STE 216
GREEN BAY WI
54303-4863
US

IV. Provider business mailing address

2701 LARSEN RD STE 216
GREEN BAY WI
54303-4863
US

V. Phone/Fax

Practice location:
  • Phone: 920-883-6995
  • Fax: 920-496-6009
Mailing address:
  • Phone: 920-883-6995
  • Fax: 920-496-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6671-123
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1598
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6671-123
License Number StateWI

VIII. Authorized Official

Name: MRS. MICHELLE R EDDY
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: MSW,LCSW
Phone: 920-883-6995