Healthcare Provider Details

I. General information

NPI: 1073639126
Provider Name (Legal Business Name): NORTH SHORE WELLNESS SERVICES, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HUEHL RD BLDG 19B
NORTHBROOK IL
60062-2323
US

IV. Provider business mailing address

425 HUEHL RD BLDG 19B
NORTHBROOK IL
60062-2323
US

V. Phone/Fax

Practice location:
  • Phone: 847-205-0371
  • Fax: 847-205-0377
Mailing address:
  • Phone: 847-205-0371
  • Fax: 847-205-0377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number180005618
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTORIA MANION FLEMING
Title or Position: PRESIDENT
Credential: PHD., LCPC, NCC
Phone: 847-205-0371