Provider Demographics
NPI:1679195580
Name:THE WELLNESS COLLECTIVE
Entity type:Organization
Organization Name:THE WELLNESS COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:BRIGGS
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:CSW-PIP
Authorized Official - Phone:605-271-5640
Mailing Address - Street 1:2333 W 57TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5054
Mailing Address - Country:US
Mailing Address - Phone:605-271-5640
Mailing Address - Fax:
Practice Address - Street 1:2333 W 57TH ST STE 103
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5054
Practice Address - Country:US
Practice Address - Phone:605-271-5640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-13
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1922396027Medicaid
SDS50694OtherMEDICARE