=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962335059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETHEREAL MUSE COLLECTIVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2026
-----------------------------------------------------
Last Update Date | 06/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4212 W HAWTHORNE TRACE RD APT 206
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-236-2745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4212 W HAWTHORNE TRACE RD APT 206
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209-1023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-236-2745
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LASHEENIA EVANS
-----------------------------------------------------
Credential | CNA
-----------------------------------------------------
Telephone | 414-236-2745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------