Provider Demographics
NPI:1093066599
Name:NORTH SHORE FAMILY WELLNESS, LLC
Entity Type:Organization
Organization Name:NORTH SHORE FAMILY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FAMILY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BAYER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-231-3729
Mailing Address - Street 1:5225 OLD ORCHARD RD STE 46
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-1027
Mailing Address - Country:US
Mailing Address - Phone:847-231-3729
Mailing Address - Fax:
Practice Address - Street 1:5225 OLD ORCHARD RD
Practice Address - Street 2:SUITE 34
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4405
Practice Address - Country:US
Practice Address - Phone:847-231-3729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-24
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490116331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty