Healthcare Provider Details

I. General information

NPI: 1023868130
Provider Name (Legal Business Name): BOUNDLESS GROWTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 JULIE LN
HAMPSHIRE IL
60140-8379
US

IV. Provider business mailing address

206 JULIE LN
HAMPSHIRE IL
60140-8379
US

V. Phone/Fax

Practice location:
  • Phone: 847-595-0662
  • Fax:
Mailing address:
  • Phone: 847-595-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: RAE MAGNANI
Title or Position: OWNER AND THERAPIST
Credential:
Phone: 847-595-0662