=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447047469
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE MENTAL WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 04/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13508 JULIE DR
-----------------------------------------------------
City | POPLAR GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61065-7829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-596-0098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13508 JULIE DR
-----------------------------------------------------
City | POPLAR GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61065-7829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-596-0098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | COURTNEY NICOLLE FORMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-209-8486
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------