Healthcare Provider Details

I. General information

NPI: 1619493855
Provider Name (Legal Business Name): BRICOLAGE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BUTTERFIELD RD STE 212
LOMBARD IL
60148-4879
US

IV. Provider business mailing address

477 E BUTTERFIELD RD STE 212
LOMBARD IL
60148-4879
US

V. Phone/Fax

Practice location:
  • Phone: 630-866-5666
  • Fax:
Mailing address:
  • Phone: 630-866-5666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180010822
License Number StateIL

VIII. Authorized Official

Name: DAWN M LEPRICH-GRAVES
Title or Position: OWNER/ CLINICAL THERAPIST
Credential: LCPC
Phone: 630-866-5666