Healthcare Provider Details

I. General information

NPI: 1962335059
Provider Name (Legal Business Name): ETHEREAL MUSE COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 W HAWTHORNE TRACE RD APT 206
MILWAUKEE WI
53209-1023
US

IV. Provider business mailing address

4212 W HAWTHORNE TRACE RD APT 206
MILWAUKEE WI
53209-1023
US

V. Phone/Fax

Practice location:
  • Phone: 414-236-2745
  • Fax:
Mailing address:
  • Phone: 414-236-2745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LASHEENIA EVANS
Title or Position: OWNER
Credential: CNA
Phone: 414-236-2745