Provider Demographics
NPI:1205469277
Name:THIRD WAVE WELLNESS, LLC
Entity type:Organization
Organization Name:THIRD WAVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BIERBAUM
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-484-7140
Mailing Address - Street 1:636 CHURCH ST STE 418
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4580
Mailing Address - Country:US
Mailing Address - Phone:773-484-7140
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST STE 418
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4580
Practice Address - Country:US
Practice Address - Phone:773-484-7140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THIRD WAVE WELLNESS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty