Provider Demographics
NPI:1417329426
Name:TWO ROADS WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:TWO ROADS WELLNESS CLINIC, LLC
Other - Org Name:TWO ROADS WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:NEMECZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:217-651-6801
Mailing Address - Street 1:3545 N VERMILION ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1100
Mailing Address - Country:US
Mailing Address - Phone:217-651-6801
Mailing Address - Fax:217-651-6802
Practice Address - Street 1:3545 N VERMILION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1100
Practice Address - Country:US
Practice Address - Phone:217-651-6801
Practice Address - Fax:217-651-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty