Healthcare Provider Details

I. General information

NPI: 1063136307
Provider Name (Legal Business Name): S & T MENTAL WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W 83RD ST STE A
CHICAGO IL
60620-1704
US

IV. Provider business mailing address

320 W 83RD ST STE A
CHICAGO IL
60620-1704
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-4758
  • Fax:
Mailing address:
  • Phone: 815-741-4758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code364SP0813X
TaxonomyGeropsychiatric Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SUKHDEV SONI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 815-741-4758