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General NPI Number Information
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NPI Number | 1346025285
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Entity Type | Organization
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Legal Business Name | FOREVERMORE MIND BODY & SOUL
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Dates
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Enumeration Date | 08/29/2023
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 411 N BLUFF ST APT 11
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City | JOLIET
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State | IL
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Zip | 60435-7295
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Country | US
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Telephone | 815-766-5999
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Fax |
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Provider Business Mailing Address
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Address Line | 411 N BLUFF ST APT 11
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City | JOLIET
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State | IL
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Zip | 60435-7295
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Country | US
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Telephone | 815-766-5999
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH PROVIDER
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Name | MR. DEMITRIUS BRACKETT
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Credential | PAIN
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Telephone | 815-766-5999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174200000X
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Taxonomy Name | Meals Provider
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QR1100X
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Taxonomy Name | Research Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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