MEDICARE: STOCKTON WELLNESS GROUP, 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1760095400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOCKTON WELLNESS GROUP, LLC

Provider Business Mailing Address
First Line	:	1844 S BLUE ISLAND AVE APT 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-0495
Country	:	US
Telephone Number	:	312-813-3134
Fax Number	:

Provider Business Practice Location Address
First Line	:	1844 S BLUE ISLAND AVE APT 2F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-0495
Country	:	US
Telephone Number	:	312-813-3134
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MEREDITH STOCKTON
Credential	:	LCSW, RYT
Telephone Number	:	312-813-3134

Provider Enumeration Date	:	08/24/2020
Last Update Date	:	08/24/2020

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