MEDICARE: HEALING SELF WELLNESS CENTER

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1659057719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING SELF WELLNESS CENTER

Provider Business Mailing Address
First Line	:	2501 CHATHAM RD STE N
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 E 50TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60615-3271
Country	:	US
Telephone Number	:	708-292-8339
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	SABLE SANDERS
Credential	:	LCSW
Telephone Number	:	773-820-2007

Provider Enumeration Date	:	06/23/2023
Last Update Date	:	06/23/2023

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