=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912536814
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STELLAR WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2020
-----------------------------------------------------
Last Update Date | 04/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1065 24TH AVE SW STE 107
-----------------------------------------------------
City | OWATONNA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55060-5063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-774-3147
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 AUGUSTA PL
-----------------------------------------------------
City | OWATONNA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55060-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-456-6123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TARA KAY JENO
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 507-456-6123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------