=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336601202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS ON THE HORIZON, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2019
-----------------------------------------------------
Last Update Date | 07/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 E EMPIRE ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-532-4572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 712 E EMPIRE ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-3252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-532-4572
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | LAURIE KROLIKOWSKI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 309-532-4572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------