Healthcare Provider Details

I. General information

NPI: 1629596812
Provider Name (Legal Business Name): MENTAL WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 KAYS DR STE C
NORMAL IL
61761-1979
US

IV. Provider business mailing address

405 KAYS DR STE C
NORMAL IL
61761-1979
US

V. Phone/Fax

Practice location:
  • Phone: 309-807-5077
  • Fax:
Mailing address:
  • Phone: 309-807-5077
  • Fax: 309-417-3550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER RAE BOVEE
Title or Position: GROUP PRACTICE OWNER
Credential: LCSW
Phone: 309-807-5077