Healthcare Provider Details

I. General information

NPI: 1073450938
Provider Name (Legal Business Name): INNERWELL THERAPEUTIC & WELLNESS SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7509 S PRAIRIE AVE
CHICAGO IL
60619-2216
US

IV. Provider business mailing address

1 E ERIE ST STE 525-2066
CHICAGO IL
60611-2740
US

V. Phone/Fax

Practice location:
  • Phone: 312-998-3072
  • Fax:
Mailing address:
  • Phone: 312-998-3072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KELLEY D BROWN
Title or Position: THERAPIST
Credential:
Phone: 312-998-3072