Healthcare Provider Details

I. General information

NPI: 1386119501
Provider Name (Legal Business Name): WELLLIFE BEHAVIORAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4137 SAUK TRAIL, SUITE 100
RICHTON PARK IL
60471
US

IV. Provider business mailing address

22801 NIAMH CT
RICHTON PARK IL
60471-1480
US

V. Phone/Fax

Practice location:
  • Phone: 773-355-1258
  • Fax: 708-631-0164
Mailing address:
  • Phone: 773-355-1258
  • Fax: 708-631-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA K. MCCLERKLIN
Title or Position: OWNER
Credential: LCSW
Phone: 773-355-1258