MEDICARE: NOURISH WELLNESS AND THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1285263178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NOURISH WELLNESS AND THERAPY LLC

Provider Business Mailing Address
First Line	:	5703 N NEWARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3140
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5703 N NEWARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-3140
Country	:	US
Telephone Number	:	757-647-0477
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIZABETH STACHULSKI
Credential	:
Telephone Number	:	757-647-0477

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	03/23/2024

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