Provider Demographics
NPI:1942702386
Name:BRAIN AND WELLNESS INSTITUTE LLC
Entity Type:Organization
Organization Name:BRAIN AND WELLNESS INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGAMANI
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVULURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-636-8671
Mailing Address - Street 1:30 W OAK ST APT 14A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-8724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 W OAK ST APT 14A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-8724
Practice Address - Country:US
Practice Address - Phone:312-636-8671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361010822084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty