Healthcare Provider Details

I. General information

NPI: 1760362198
Provider Name (Legal Business Name): ENVISIONING CROWN WIGS CRANIAL PROSTHESIS SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2025
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 BROWN BLVD STE 102
BOURBONNAIS IL
60914-2325
US

IV. Provider business mailing address

475 BROWN BLVD STE 102
BOURBONNAIS IL
60914-2325
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-7962
  • Fax: 815-936-8650
Mailing address:
  • Phone: 815-937-7962
  • Fax: 815-936-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MS. CAMELA ROSENTHAL
Title or Position: CEO
Credential: C.P.S.
Phone: 815-386-6568