Healthcare Provider Details

I. General information

NPI: 1417329426
Provider Name (Legal Business Name): TWO ROADS WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 N VERMILION ST
DANVILLE IL
61832-1100
US

IV. Provider business mailing address

3545 N VERMILION ST
DANVILLE IL
61832-1100
US

V. Phone/Fax

Practice location:
  • Phone: 217-651-6801
  • Fax: 217-651-6802
Mailing address:
  • Phone: 217-651-6801
  • Fax: 217-651-6802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. JESSICA NEMECZ
Title or Position: COUNSELOR
Credential: LCPC
Phone: 217-651-6801