NPIMap

Organization Active NPI

Lake Geneva Wellness Clinic LLC

  • Clinical Psychologist
  • Lake Geneva, WI
National Provider Identifier
1003845181
Registry record updated Sep 12, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
811-057 Issued in WI
Legal business name
LAKE GENEVA WELLNESS CLINIC LLC
Practice address
750 Veterans Pkwy Unit 100
Lake Geneva, WI 53147-4950
Phone
(262) 248-7942
Fax
(262) 248-1202
NPI assigned
Jul 1, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 12, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Erika K Fountain, LPC W/AODA SPECIALTYNPI 1306023932
Title
Owner
Phone
(262) 248-7942

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC0700X 811-057 WI Primary

Addresses

Primary practice location

750 Veterans Pkwy Unit 100
Lake Geneva, WI 53147-4950

Mailing address

750 Veterans Pkwy Unit 100
Lake Geneva, WI 53147-4950
Phone (262) 248-7942

Other identifiers 1

IdentifierTypeStateIssuer
42126800MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111018000668 WI Part B Supplier - Clinic/Group Practice 7517139447 Receives reassigned benefits from 7 practitioners
Practice locations: Lake Geneva, WI

National Provider Directory

National Provider Directory

Locations

750 Veterans Pkwy
Unit 100
Lake Geneva, WI 53147
Phone (262) 248-7942

101 Broad St
Ste 201
Lake Geneva, WI 53147
Phone (262) 248-7942

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1726099200000",
    "number": "1003845181",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 VETERANS PKWY UNIT 100",
            "city": "LAKE GENEVA",
            "state": "WI",
            "postal_code": "531474950",
            "telephone_number": "262-248-7942",
            "fax_number": "262-248-1202"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 VETERANS PKWY UNIT 100",
            "city": "LAKE GENEVA",
            "state": "WI",
            "postal_code": "531474950",
            "telephone_number": "262-248-7942",
            "fax_number": "262-248-1202"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKE GENEVA WELLNESS CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-01",
        "last_updated": "2024-09-12",
        "certification_date": "2024-09-12",
        "status": "A",
        "authorized_official_last_name": "FOUNTAIN",
        "authorized_official_first_name": "ERIKA",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "262-248-7942",
        "authorized_official_credential": "LPC W/AODA SPECIALTY"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical",
            "state": "WI",
            "license": "811-057",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "42126800",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lake Geneva, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.