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General NPI Number Information
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NPI Number | 1770801003
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Entity Type | Organization
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Legal Business Name | THE WELLNESS LIVING CENTER, LLC
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Dates
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Enumeration Date | 05/11/2010
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Last Update Date | 05/11/2010
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Provider Practice Location Address
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Address Line | 10088 199TH ST W
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City | LAKEVILLE
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State | MN
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Zip | 55044-6266
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Country | US
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Telephone | 612-598-3891
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Fax |
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Provider Business Mailing Address
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Address Line | 10088 199TH ST W
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City | LAKEVILLE
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State | MN
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Zip | 55044-6266
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Country | US
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Telephone | 612-598-3891
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | KATHRYN L CASHMAN
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Credential | M.A., L.P.
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Telephone | 612-598-3891
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0089
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License Number State | MN
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