MEDICARE: REWIRED THERAPY PLLC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1275393993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REWIRED THERAPY PLLC

Provider Business Mailing Address
First Line	:	73 FOXCROFT RD
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60565-2307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3420 LACROSSE LN STE 107
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-8279
Country	:	US
Telephone Number	:	630-447-0238
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHAWN WUNDERLICH
Credential	:	PHD, LCPC
Telephone Number	:	309-714-9589

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	03/20/2024

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