| Grace Healing And Wellness Center, Llc. | |
|
N28w23000 Roundy Dr Ste 105 Pewaukee WI 53072-7300 | |
| (414) 350-6693 | |
| Not Available |
| Full Name | Grace Healing And Wellness Center, Llc. |
|---|---|
| Speciality | Psychologist |
| Location | N28w23000 Roundy Dr Ste 105, Pewaukee, Wisconsin |
| Authorized Official Name and Position | Angelique Lewis (PSYCHOLOGIST) |
| Authorized Official Contact | 4143506693 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Grace Healing And Wellness Center, Llc. N28w23000 Roundy Dr Ste 105 Pewaukee WI 53072-7300 Ph: (414) 350-6693 | Grace Healing And Wellness Center, Llc. N28w23000 Roundy Dr Ste 105 Pewaukee WI 53072-7300 Ph: (414) 350-6693 |
| NPI Number | 1467190694 |
|---|---|
| Provider Enumeration Date | 05/26/2022 |
| Last Update Date | 05/26/2022 |
| Certification Date | 05/26/2022 |
| Medicare PECOS PAC ID | 3971986506 |
|---|---|
| Medicare Enrollment ID | O20220815003554 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1467190694 | NPI | - | NPPES |
| 100003219 | Medicaid | WI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | Angelique W Lewis |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1295979714 PECOS PAC ID: 1355525510 Enrollment ID: I20110412000948 |
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