MEDICARE: VILLAGE & VINE WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker
4	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1821952110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE & VINE WELLNESS

Provider Business Mailing Address
First Line	:	536 E 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7451
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	536 E 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-7451
Country	:	US
Telephone Number	:	312-600-0954
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SHANNON MCCRAY
Credential	:
Telephone Number	:	312-600-0954

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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Directions to “VILLAGE & VINE WELLNESS ” Practice Location

Language	Start Address	Practice Location

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