Basic Information
| Provider Information | |||||||||
| NPI: | 1235373325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORAL WELLNESS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2614 122ND PL | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604061014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124699617 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2614 122ND PL | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604061014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124699617 | ||||||||
| FaxNumber: | 7737512250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2009 | ||||||||
| LastUpdateDate: | 05/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | MAJOR | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3124699617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker |
No ID Information.