Healthcare Provider Details

I. General information

NPI: 1134199037
Provider Name (Legal Business Name): COMWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10257 STATE ROUTE 3
RED BUD IL
62278-4418
US

IV. Provider business mailing address

10257 STATE ROUTE 3
RED BUD IL
62278-4418
US

V. Phone/Fax

Practice location:
  • Phone: 618-282-6233
  • Fax: 618-282-6949
Mailing address:
  • Phone: 618-282-6233
  • Fax: 618-282-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: AMY BAUER
Title or Position: IT COORDINATOR
Credential:
Phone: 618-282-6233