Healthcare Provider Details

I. General information

NPI: 1043122849
Provider Name (Legal Business Name): LIVEWELL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 MAIN ST APT 5
UNION GROVE WI
53182-1343
US

IV. Provider business mailing address

3635 BRITTON RDG
UNION GROVE WI
53182-9360
US

V. Phone/Fax

Practice location:
  • Phone: 262-232-4290
  • Fax:
Mailing address:
  • Phone: 262-939-3936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DEREK ALCALA
Title or Position: LPC
Credential:
Phone: 262-939-3936