Healthcare Provider Details

I. General information

NPI: 1407674492
Provider Name (Legal Business Name): NOURISH WELL COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 CRESCENT BLVD STE 210
GLEN ELLYN IL
60137-4177
US

IV. Provider business mailing address

526 CRESCENT BLVD STE 210
GLEN ELLYN IL
60137-4177
US

V. Phone/Fax

Practice location:
  • Phone: 847-533-9760
  • Fax:
Mailing address:
  • Phone: 847-533-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA SCANLON
Title or Position: LCPC/ OWNER
Credential: MA, LCPC
Phone: 847-533-9760