MEDICARE: RAW 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1104645027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAW WELLNESS LLC

Provider Business Mailing Address
First Line	:	4855 W WINNEMAC AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2432
Country	:	US
Telephone Number	:	773-931-6006
Fax Number	:

Provider Business Practice Location Address
First Line	:	4855 W WINNEMAC AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-2432
Country	:	US
Telephone Number	:	773-931-6006
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	REBECCA WELLES
Credential	:
Telephone Number	:	773-931-6006

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	04/21/2025

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Directions to “RAW WELLNESS LLC ” Practice Location

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