Basic Information
| Provider Information | |||||||||
| NPI: | 1467057224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLBORN | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | |||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 E HAWTHORN PKWY STE 235 | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600611454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 MARNE HWY STE 108 | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329822888 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 44SL06105900 | NJ | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.