=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427793876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAILHEADS: ADVENTURES IN MIND, BODY AND SPIRIT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2022
-----------------------------------------------------
Last Update Date | 04/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3265 BENSON RD
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-9716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-674-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3265 BENSON RD
-----------------------------------------------------
City | MORRIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60450-9716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-674-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP-BC
-----------------------------------------------------
Name | THERESA DONLEY
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 815-674-1191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------