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General NPI Number Information
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NPI Number | 1336759620
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Entity Type | Organization
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Legal Business Name | TELOS HEALTH AND WELLNESS SERVICES, LLC
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Dates
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Enumeration Date | 08/03/2020
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 100 N CHESTNUT ST. STE 235
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City | CHAMPAIGN
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State | IL
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Zip | 61820-4872
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Country | US
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Telephone | 217-292-7262
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Fax | 217-209-5798
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Provider Business Mailing Address
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Address Line | 2005 N. PROSPECT AVE PMB 1178
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City | CHAMPAIGN
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State | IL
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Zip | 61822-1235
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Country | US
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Telephone | 217-292-7262
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Fax | 217-209-5798
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Authorized Official
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Title or Position | CLINICAL COUNSELOR
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Name | MRS. MARISSA JONAL HARRIS
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Credential | LCSW
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Telephone | 217-898-5160
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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 |
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License Number State |
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