Healthcare Provider Details

I. General information

NPI: 1164326591
Provider Name (Legal Business Name): ORIGEN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MASON ST UNIT 405
MILWAUKEE WI
53202-3572
US

IV. Provider business mailing address

104 E MASON ST UNIT 405
MILWAUKEE WI
53202-3572
US

V. Phone/Fax

Practice location:
  • Phone: 414-391-7413
  • Fax:
Mailing address:
  • Phone: 414-391-7413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: VERONICA CRUZ
Title or Position: OWNER
Credential: LPC-IT
Phone: 414-391-7413