Healthcare Provider Details

I. General information

NPI: 1326966375
Provider Name (Legal Business Name): AMETHYST WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6302 ODANA RD STE 215
MADISON WI
53719-1162
US

IV. Provider business mailing address

PO BOX 127
MAZOMANIE WI
53560-0127
US

V. Phone/Fax

Practice location:
  • Phone: 608-709-9575
  • Fax: 608-714-4010
Mailing address:
  • Phone: 608-709-9575
  • Fax: 608-714-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KELLY RAUFMAN
Title or Position: AGENCY DIRECTOR
Credential: LCSW
Phone: 608-531-8578