Healthcare Provider Details

I. General information

NPI: 1316477938
Provider Name (Legal Business Name): BROADLEAF HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 GROVE AVE
BERWYN IL
60402-3474
US

IV. Provider business mailing address

3245 GROVE AVE
BERWYN IL
60402-3474
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-4607
  • Fax:
Mailing address:
  • Phone: 773-947-4607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MARIA ESPEJO-SCHILTZ
Title or Position: WELLNESS PRACTITIONER
Credential: OT
Phone: 773-947-4607