=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700512159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUNOIA WELLNESS BOUTIQUE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2022
-----------------------------------------------------
Last Update Date | 07/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17901 GOVERNORS HWY STE 30
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-319-5669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17901 GOVERNORS HWY STE 30
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60430-1145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-319-5669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ARIELLE SMITH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 224-326-0128
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------