Healthcare Provider Details

I. General information

NPI: 1346025285
Provider Name (Legal Business Name): FOREVERMORE MIND BODY & SOUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N BLUFF ST APT 11
JOLIET IL
60435-7295
US

IV. Provider business mailing address

411 N BLUFF ST APT 11
JOLIET IL
60435-7295
US

V. Phone/Fax

Practice location:
  • Phone: 815-766-5999
  • Fax:
Mailing address:
  • Phone: 815-766-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DEMITRIUS BRACKETT
Title or Position: MENTAL HEALTH PROVIDER
Credential: PAIN
Phone: 815-766-5999