Healthcare Provider Details

I. General information

NPI: 1699685834
Provider Name (Legal Business Name): 11:11 COURAGEOUS WELLBEING COLLABORATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2513A S KINNICKINNIC AVE
MILWAUKEE WI
53207-1619
US

IV. Provider business mailing address

2513A S KINNICKINNIC AVE
MILWAUKEE WI
53207-1619
US

V. Phone/Fax

Practice location:
  • Phone: 920-932-1013
  • Fax:
Mailing address:
  • Phone: 920-932-1013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. LANE MELANIE MOREIN
Title or Position: OWNER
Credential: LCSW
Phone: 920-932-1013