MEDICARE: BE WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1063178069
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BE WELLNESS, LLC

Provider Business Mailing Address
First Line	:	9449 S KEDZIE AVE # 533
Second Line	:
City	:	EVERGREEN PARK
State	:	IL
Zip	:	60805-2325
Country	:	US
Telephone Number	:	177-358-7824
Fax Number	:

Provider Business Practice Location Address
First Line	:	64 E BROADWAY RD STE 280
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-1353
Country	:	US
Telephone Number	:	773-587-8240
Fax Number	:	773-526-7634

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THERESA DENISE MOORE
Credential	:	ED.D, LCPC
Telephone Number	:	773-587-8240

Provider Enumeration Date	:	11/14/2021
Last Update Date	:	11/14/2021

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Directions to “BE WELLNESS, LLC ” Practice Location

Language	Start Address	Practice Location

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