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General NPI Number Information
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NPI Number | 1154886455
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Entity Type | Organization
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Legal Business Name | WELLNESS MADE WHOLE INC
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Dates
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Enumeration Date | 01/31/2019
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Last Update Date | 01/31/2019
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Provider Practice Location Address
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Address Line | 1175 LILY CACHE LN
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City | BOLINGBROOK
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State | IL
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Zip | 60490-3122
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Country | US
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Telephone | 815-290-9048
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Fax |
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Provider Business Mailing Address
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Address Line | 1175 LILY CACHE LN
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City | BOLINGBROOK
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State | IL
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Zip | 60490-3122
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Country | US
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Telephone | 815-290-9048
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. KIYANA JACKSON
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Credential | LCPC
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Telephone | 708-997-1301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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