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General NPI Number Information
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NPI Number | 1467190694
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Entity Type | Organization
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Legal Business Name | GRACE HEALING AND WELLNESS CENTER, LLC.
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 05/26/2022
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Provider Practice Location Address
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Address Line | N28W23000 ROUNDY DR STE 105
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City | PEWAUKEE
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State | WI
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Zip | 53072-7300
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Country | US
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Telephone | 414-350-6693
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Fax |
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Provider Business Mailing Address
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Address Line | N28W23000 ROUNDY DR STE 105
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City | PEWAUKEE
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State | WI
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Zip | 53072-7300
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Country | US
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Telephone | 414-350-6693
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | ANGELIQUE LEWIS
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Credential | PHD
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Telephone | 414-350-6693
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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 |
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License Number State |
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