Healthcare Provider Details

I. General information

NPI: 1477952562
Provider Name (Legal Business Name): ARDENT COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3166 N LINCOLN AVE SUITE 401
CHICAGO IL
60657-3133
US

IV. Provider business mailing address

684 S BARRINGTON RD STUITE 112
STREAMWOOD IL
60107-1841
US

V. Phone/Fax

Practice location:
  • Phone: 630-473-3091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number15018
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL

VIII. Authorized Official

Name: STEPHEN BAYNES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 630-473-3091