Healthcare Provider Details

I. General information

NPI: 1790460616
Provider Name (Legal Business Name): BWELL COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18700 WOLF RD STE 209
MOKENA IL
60448-8699
US

IV. Provider business mailing address

13824 W CHASE CT
MANHATTAN IL
60442-9457
US

V. Phone/Fax

Practice location:
  • Phone: 708-540-3951
  • Fax:
Mailing address:
  • Phone: 815-715-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KIMBER LUBERT
Title or Position: CHILD COUNSELOR
Credential: LCPC, RPT
Phone: 815-715-5679