Provider Demographics
NPI:1285207571
Name:INTERLUDE WELLNESS PLLC
Entity Type:Organization
Organization Name:INTERLUDE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR & THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-247-1978
Mailing Address - Street 1:738 E DUNDEE RD # 128
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60074-2858
Mailing Address - Country:US
Mailing Address - Phone:630-247-1978
Mailing Address - Fax:
Practice Address - Street 1:969 NORTH CARMEL DRIVE
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60074
Practice Address - Country:US
Practice Address - Phone:630-247-1978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-23
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)