Provider Demographics
NPI:1447099825
Name:WHEELHOUSE THERAPY, LLC
Entity type:Organization
Organization Name:WHEELHOUSE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:417-543-3043
Mailing Address - Street 1:2135 E INDEPENDENCE ST # 1033
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-3749
Mailing Address - Country:US
Mailing Address - Phone:417-543-3043
Mailing Address - Fax:
Practice Address - Street 1:1722 S GLENSTONE AVE STE H
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1513
Practice Address - Country:US
Practice Address - Phone:417-543-3043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)