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General NPI Number Information
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NPI Number | 1134625007
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Entity Type | Organization
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Legal Business Name | MIDWEST WELLNESS LLC
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Dates
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Enumeration Date | 04/01/2018
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Last Update Date | 02/20/2024
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Provider Practice Location Address
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Address Line | 24 N SAINT JOSEPH AVE STE C2
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City | NILES
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State | MI
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Zip | 49120-2263
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Country | US
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Telephone | 269-262-1815
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Fax |
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Provider Business Mailing Address
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Address Line | 20 N 2ND ST STE 103
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City | NILES
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State | MI
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Zip | 49120-2259
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Country | US
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Telephone | 269-262-1815
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CULLEN HARDY
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Credential | PSYD
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Telephone | 269-262-1815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6401013717
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License Number State | MI
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