Healthcare Provider Details

I. General information

NPI: 1497910103
Provider Name (Legal Business Name): MAEHNOWESEKIYAH WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

IV. Provider business mailing address

N2150 KESAEHKAHTEK RD
GRESHAM WI
54128-9602
US

V. Phone/Fax

Practice location:
  • Phone: 715-799-3835
  • Fax: 715-799-3836
Mailing address:
  • Phone: 715-799-3835
  • Fax: 715-799-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1554
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier42151300
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name: ADDIE MAE CALDWELL
Title or Position: DIRECTOR OF WELLNESS PROGRAMS
Credential: MA, LPC
Phone: 715-799-3835