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General NPI Number Information
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NPI Number | 1023350063
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Entity Type | Organization
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Legal Business Name | WISE ROOTS WELLNESS, LLC
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Dates
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Enumeration Date | 03/16/2013
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Last Update Date | 03/16/2013
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Provider Practice Location Address
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Address Line | 3600 W WRIGHTWOOD AVE
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City | CHICAGO
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State | IL
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Zip | 60647-1138
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Country | US
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Telephone | 312-445-8906
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Fax |
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Provider Business Mailing Address
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Address Line | 2619 W ATTRILL ST
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City | CHICAGO
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State | IL
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Zip | 60647-4003
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VIRGINIA WYATT WHARTON
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Credential |
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Telephone | 312-259-2112
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149015015
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License Number State | IL
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