Healthcare Provider Details

I. General information

NPI: 1609709435
Provider Name (Legal Business Name): EMBRACE LIFE TRAUMA INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E WISCONSIN AVE STE 204A
OCONOMOWOC WI
53066-3058
US

IV. Provider business mailing address

PO BOX 432
OCONOMOWOC WI
53066-0432
US

V. Phone/Fax

Practice location:
  • Phone: 262-341-9533
  • Fax:
Mailing address:
  • Phone: 262-341-9533
  • 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: KIMBERLY NICOLE REZARCH
Title or Position: FOUNER CEO
Credential: LCSW
Phone: 920-253-5523