Healthcare Provider Details

I. General information

NPI: 1255952255
Provider Name (Legal Business Name): AGE WISE CARE MANAGEMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W TOMARAS AVE STE 5152
SAVOY IL
61874-9547
US

IV. Provider business mailing address

101 W TOMARAS AVE STE 5152
SAVOY IL
61874-9547
US

V. Phone/Fax

Practice location:
  • Phone: 217-493-3086
  • Fax: 888-456-5007
Mailing address:
  • Phone: 217-493-3086
  • Fax: 888-456-5007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA A CRONIN
Title or Position: OWNER/COUNSELOR
Credential: LCPC, CRC, CCM
Phone: 217-493-3086