Healthcare Provider Details

I. General information

NPI: 1063155943
Provider Name (Legal Business Name): OLIPHANT THERAPY AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 S CANAL ST # 1249
CHICAGO IL
60607-4907
US

IV. Provider business mailing address

2501 CHATHAM RD STE R
SPRINGFIELD IL
62704-4188
US

V. Phone/Fax

Practice location:
  • Phone: 224-269-0286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EBONY OLIPHANT
Title or Position: OWNER
Credential:
Phone: 224-269-0286