Healthcare Provider Details

I. General information

NPI: 1356987184
Provider Name (Legal Business Name): AUNT MARTHA'S HEALTH AND WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 S MICHIGAN AVE STE B
CHICAGO IL
60615
US

IV. Provider business mailing address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 877-692-8686
  • Fax:
Mailing address:
  • Phone: 708-747-7100
  • 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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA BORRAYO
Title or Position: DIRECTOR OF PATIENT ACCESS
Credential:
Phone: 708-825-7511