MEDICARE: INNERWELL THERAPEUTIC & WELLNESS SERVICES, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1073450938
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNERWELL THERAPEUTIC & WELLNESS SERVICES, LLC

Provider Business Mailing Address
First Line	:	1 E ERIE ST STE 525-2066
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-2740
Country	:	US
Telephone Number	:	312-998-3072
Fax Number	:

Provider Business Practice Location Address
First Line	:	7509 S PRAIRIE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-2216
Country	:	US
Telephone Number	:	312-998-3072
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	KELLEY D BROWN
Credential	:
Telephone Number	:	312-998-3072

Provider Enumeration Date	:	04/30/2026
Last Update Date	:	04/30/2026

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