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General NPI Number Information
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NPI Number | 1124730023
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Entity Type | Organization
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Legal Business Name | EMBODIED-WELLLBEING
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Dates
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Enumeration Date | 12/22/2022
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 2501 JENNY LANE
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City | GREEN BAY
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State | WI
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Zip | 54302
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Country | US
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Telephone | 920-212-7523
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Fax |
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Provider Business Mailing Address
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Address Line | 2501 JENNY LN APT 8
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City | GREEN BAY
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State | WI
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Zip | 54302-5039
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Country | US
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Telephone | 920-521-8940
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Fax |
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Authorized Official
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Title or Position | CLINICAL THERAPIST
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Name | MR. KEITH PAUL NEILITZ
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Credential | LPC
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Telephone | 920-521-8940
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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