Provider Demographics
NPI:1326641986
Name:BROADLEAF HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:BROADLEAF HEALTH AND WELLNESS
Other - Org Name:BROADLEAF HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REHAB PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPEJO
Authorized Official - Suffix:
Authorized Official - Credentials:OT, CCCPA,CIMT,CMT
Authorized Official - Phone:773-497-4607
Mailing Address - Street 1:3245 GROVE AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3476
Mailing Address - Country:US
Mailing Address - Phone:773-947-4607
Mailing Address - Fax:
Practice Address - Street 1:3245 GROVE AVE STE 205
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3476
Practice Address - Country:US
Practice Address - Phone:773-947-4607
Practice Address - Fax:773-439-2552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROADLEAF HEALTH AND WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-17
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty