Provider Demographics
NPI:1215764873
Name:CHICAGO WELLNESS AND SUPPORT LLC
Entity type:Organization
Organization Name:CHICAGO WELLNESS AND SUPPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-619-0949
Mailing Address - Street 1:16211 N SCOTTSDALE RD STE A6A267
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1584
Mailing Address - Country:US
Mailing Address - Phone:480-619-0949
Mailing Address - Fax:
Practice Address - Street 1:2833 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-5213
Practice Address - Country:US
Practice Address - Phone:773-873-7335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-17
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health