Provider Demographics
NPI:1619189594
Name:COMMON BOUNDARY WELLNESS CENTER
Entity Type:Organization
Organization Name:COMMON BOUNDARY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCARDLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:815-965-1817
Mailing Address - Street 1:1495 NORTHROCK CT
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1233
Mailing Address - Country:US
Mailing Address - Phone:815-965-1817
Mailing Address - Fax:815-965-9574
Practice Address - Street 1:1495 NORTHROCK CT
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1233
Practice Address - Country:US
Practice Address - Phone:815-965-1817
Practice Address - Fax:815-965-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty