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General NPI Number Information
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NPI Number | 1629596812
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Entity Type | Organization
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Legal Business Name | MENTAL WELLNESS CENTER INC
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Dates
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Enumeration Date | 09/07/2017
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Last Update Date | 08/27/2021
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Provider Practice Location Address
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Address Line | 205 N WILLIAMSBURG DR STE A
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City | BLOOMINGTON
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State | IL
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Zip | 61704-7721
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Country | US
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Telephone | 309-807-5077
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Fax | 309-214-9679
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Provider Business Mailing Address
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Address Line | 202 N PROSPECT RD STE 205
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City | BLOOMINGTON
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State | IL
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Zip | 61704-7920
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Country | US
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Telephone | 309-445-0394
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Fax | 309-417-3550
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Authorized Official
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Title or Position | GROUP PRACTICE OWNER
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Name | JENNIFER RAE BOVEE
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Credential | LCSW
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Telephone | 309-807-5077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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