Provider Demographics
NPI:1073639126
Name:NORTH SHORE WELLNESS SERVICES, LTD.
Entity type:Organization
Organization Name:NORTH SHORE WELLNESS SERVICES, LTD.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MANION
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCPC, NCC
Authorized Official - Phone:847-205-0371
Mailing Address - Street 1:425 HUEHL RD BLDG 19B
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2323
Mailing Address - Country:US
Mailing Address - Phone:847-205-0371
Mailing Address - Fax:847-205-0377
Practice Address - Street 1:425 HUEHL RD BLDG 19B
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2323
Practice Address - Country:US
Practice Address - Phone:847-205-0371
Practice Address - Fax:847-205-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0850X, 101Y00000X, 103TC1900X, 261QM0801X, 101YM0800X
IL180005618251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)