Healthcare Provider Details

I. General information

NPI: 1851003826
Provider Name (Legal Business Name): EMBODIED-WELLBEING LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 05/27/2023
Certification Date: 05/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 LARSEN RD # BA109
GREEN BAY WI
54303-4863
US

IV. Provider business mailing address

2701 LARSEN RD # BA109
GREEN BAY WI
54303-4863
US

V. Phone/Fax

Practice location:
  • Phone: 920-521-8940
  • Fax:
Mailing address:
  • Phone: 920-521-8940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KEITH PAUL NEILITZ
Title or Position: CLINICAL THERAPIST
Credential: LPC
Phone: 920-521-8940