Provider Demographics
NPI:1770346702
Name:VELVAERE MENTAL HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:VELVAERE MENTAL HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OFFICE MANAGER/CLINICAL SUPER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLINGWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS,LPC,SAC,ICS
Authorized Official - Phone:608-695-0960
Mailing Address - Street 1:100 BUSINESS PARK CIR STE 202
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-5501
Mailing Address - Country:US
Mailing Address - Phone:608-205-8308
Mailing Address - Fax:
Practice Address - Street 1:100 BUSINESS PARK CIR STE 202
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-5501
Practice Address - Country:US
Practice Address - Phone:608-205-8308
Practice Address - Fax:608-719-3418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty