Provider Demographics
NPI:1689926487
Name:WELLNESS LOFT INC.
Entity Type:Organization
Organization Name:WELLNESS LOFT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCPC
Authorized Official - Phone:217-347-5118
Mailing Address - Street 1:408 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3703
Mailing Address - Country:US
Mailing Address - Phone:217-347-5118
Mailing Address - Fax:217-347-7609
Practice Address - Street 1:408 SOUTH 4TH ST.
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401
Practice Address - Country:US
Practice Address - Phone:217-347-5118
Practice Address - Fax:217-347-7609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006036101YP2500X
IL180000748101YP2500X
IL180002037101YP2500X
IL1490113371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty