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General NPI Number Information
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NPI Number | 1619888591
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Entity Type | Organization
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Legal Business Name | MIDWEST AGRICULTURAL WELLNESS INSTITUTE
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Dates
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Enumeration Date | 09/17/2026
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Last Update Date | 09/17/2026
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Provider Practice Location Address
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Address Line | 1517 E DEYOUNG ST
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City | MARION
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State | IL
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Zip | 62959-5013
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Country | US
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Telephone | 618-579-4716
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Fax |
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Provider Business Mailing Address
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Address Line | 595 BARTER RD SALINE COUNTY
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City | HARRISBURG
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State | IL
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Zip | 62946-4102
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Country | US
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Telephone | 618-579-4716
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | TINA MARTIN
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Credential |
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Telephone | 618-579-4716
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health 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 | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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