Provider Demographics
NPI:1760917223
Name:PEPONI WELLNESS LLC
Entity Type:Organization
Organization Name:PEPONI WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHRYN
Authorized Official - Last Name:REHARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:410-216-4411
Mailing Address - Street 1:PO BOX 408909
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-0020
Mailing Address - Country:US
Mailing Address - Phone:410-216-4411
Mailing Address - Fax:
Practice Address - Street 1:4305 N LINCOLN AVE STE D
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1807
Practice Address - Country:US
Practice Address - Phone:410-216-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2020-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty