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General NPI Number Information
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NPI Number | 1003845181
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Entity Type | Organization
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Legal Business Name | LAKE GENEVA WELLNESS CLINIC LLC
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 09/12/2024
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Provider Practice Location Address
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Address Line | 750 VETERANS PKWY UNIT 100
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City | LAKE GENEVA
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State | WI
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Zip | 53147-4950
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Country | US
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Telephone | 262-248-7942
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Fax | 262-248-1202
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Provider Business Mailing Address
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Address Line | 750 VETERANS PKWY UNIT 100
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City | LAKE GENEVA
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State | WI
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Zip | 53147-4950
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Country | US
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Telephone | 262-248-7942
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Fax | 262-248-1202
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Authorized Official
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Title or Position | OWNER
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Name | ERIKA K FOUNTAIN
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Credential | LPC W/AODA SPECIALTY
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Telephone | 262-248-7942
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 811-057
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License Number State | WI
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