Healthcare Provider Details

I. General information

NPI: 1487595757
Provider Name (Legal Business Name): MARSHMALLOWS HOPE NONPROFIT ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 E MADISON ST STE 4N
SPRINGFIELD IL
62701-3133
US

IV. Provider business mailing address

319 E MADISON ST STE 4N
SPRINGFIELD IL
62701-3133
US

V. Phone/Fax

Practice location:
  • Phone: 888-277-4028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LESLIE ELMER
Title or Position: CREDENTIALING MANAGER
Credential: CPCS
Phone: 608-352-8323