Provider Demographics
NPI: | 1629596812 |
---|---|
Name: | MENTAL WELLNESS CENTER INC |
Entity Type: | Organization |
Organization Name: | MENTAL WELLNESS CENTER INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | GROUP PRACTICE OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNIFER |
Authorized Official - Middle Name: | RAE |
Authorized Official - Last Name: | BOVEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 309-807-5077 |
Mailing Address - Street 1: | 202 N PROSPECT RD STE 205 |
Mailing Address - Street 2: | |
Mailing Address - City: | BLOOMINGTON |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61704-7920 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 309-445-0394 |
Mailing Address - Fax: | 309-417-3550 |
Practice Address - Street 1: | 205 N WILLIAMSBURG DR STE A |
Practice Address - Street 2: | |
Practice Address - City: | BLOOMINGTON |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61704-7721 |
Practice Address - Country: | US |
Practice Address - Phone: | 309-807-5077 |
Practice Address - Fax: | 309-214-9679 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-09-07 |
Last Update Date: | 2021-08-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Single Specialty |