Provider Demographics
NPI:1336759620
Name:TELOS HEALTH AND WELLNESS SERVICES, LLC
Entity type:Organization
Organization Name:TELOS HEALTH AND WELLNESS SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:JONAL
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-898-5160
Mailing Address - Street 1:907 W MARKETVIEW DR STE 10
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1250
Mailing Address - Country:US
Mailing Address - Phone:217-898-5160
Mailing Address - Fax:
Practice Address - Street 1:907 W MARKETVIEW DR STE 10
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1250
Practice Address - Country:US
Practice Address - Phone:217-898-5160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty