MEDICARE: IMPACT WELLNESS SERVICES, 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1740702968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	2117 PRENTISS DR APT K212
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-2217
Country	:	US
Telephone Number	:	586-354-8383
Fax Number	:

Provider Business Practice Location Address
First Line	:	2117 PRENTISS DR APT K212
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60516-2217
Country	:	US
Telephone Number	:	586-354-8383
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAMONT JONES
Credential	:
Telephone Number	:	586-354-8383

Provider Enumeration Date	:	07/10/2017
Last Update Date	:	07/21/2022

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Directions to “IMPACT WELLNESS SERVICES, LLC ” Practice Location

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