Healthcare Provider Details

I. General information

NPI: 1679907463
Provider Name (Legal Business Name): MIDWAY MEDIATION & COACHING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 THREE OAKS RD STE 2B
CARY IL
60013-6119
US

IV. Provider business mailing address

2615 THREE OAKS RD STE 2B
CARY IL
60013-6119
US

V. Phone/Fax

Practice location:
  • Phone: 224-523-0769
  • Fax: 888-972-5628
Mailing address:
  • Phone: 224-523-0769
  • Fax: 888-972-5628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149011403
License Number StateIL

VIII. Authorized Official

Name: MICHELLE ANNE GREEN
Title or Position: OWNER/PRESIDENT
Credential: LCSW
Phone: 224-523-0769