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General NPI Number Information
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NPI Number | 1770310799
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Entity Type | Organization
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Legal Business Name | RADICAL WELLNESS LLC
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Dates
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Enumeration Date | 09/14/2024
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Last Update Date | 09/14/2024
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Provider Practice Location Address
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Address Line | 2524 1ST AVE
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City | HIBBING
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State | MN
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Zip | 55746-2243
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Country | US
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Telephone | 218-996-2144
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Fax |
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Provider Business Mailing Address
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Address Line | 2524 1ST AVE
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City | HIBBING
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State | MN
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Zip | 55746-2243
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ELIZABETH MOUSSEAU MALDONADO
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Credential | LCSW
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Telephone | 218-996-2144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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