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NPI Code Detail

MEDICARE: TWO ROADS WELLNESS CLINIC, LLC

MEDICARE: TWO ROADS WELLNESS CLINIC, 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
1363L00000XNurse Practitioner
2101Y00000XCounselor
3261QP2000XPhysical Therapy Clinic/Center
4251S00000XCommunity/Behavioral Health Agency
5363LP2300XPrimary Care Nurse Practitioner

General Provider Information

NPI Number : 1417329426
Entity Type Code : Organization
Provider Name (Legal Business Name) : TWO ROADS WELLNESS CLINIC, LLC
Provider Business Mailing Address
First Line : 3545 N VERMILION ST
Second Line :
City : DANVILLE
State : IL
Zip : 61832-1100
Country : US
Telephone Number : 217-651-6801
Fax Number : 217-651-6802
Provider Business Practice Location Address
First Line : 3545 N VERMILION ST
Second Line :
City : DANVILLE
State : IL
Zip : 61832-1100
Country : US
Telephone Number : 217-651-6801
Fax Number : 217-651-6802
Authorized Official
Title or Position : COUNSELOR
Name : MRS. JESSICA NEMECZ
Credential : LCPC
Telephone Number : 217-651-6801
Provider Enumeration Date : 10/29/2015
Last Update Date : 05/14/2026

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