Healthcare Provider Details

I. General information

NPI: 1326861907
Provider Name (Legal Business Name): LIFE IMPACT CIRCLES OF WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 HIGHKNOB RD
BOLINGBROOK IL
60440-3268
US

IV. Provider business mailing address

1112 W BOUGHTON RD # 146
BOLINGBROOK IL
60440-1508
US

V. Phone/Fax

Practice location:
  • Phone: 312-561-4292
  • Fax:
Mailing address:
  • Phone: 312-561-4292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA COOK
Title or Position: PRACTICE OWNER/SOLE THERAPYPROVIDER
Credential: DRPH, LCPC, LPCC
Phone: 312-561-4292