Organization
LAKE GENEVA WELLNESS CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ERIKA K FOUNTAIN LPC W/AODA SPECIALTY (OWNER)
(262) 248-7942
Entity
Organization
Contact information
Practice address
750 VETERANS PKWY UNIT 100, LAKE GENEVA, WI 53147-4950
(262) 248-7942
(262) 248-1202
Mailing address
750 VETERANS PKWY UNIT 100, LAKE GENEVA, WI 53147-4950
(262) 248-7942
(262) 248-1202
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
811-057
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
42126800
—
WI
Enumeration date
07/01/2006
Last updated
09/12/2024
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