Provider Demographics
NPI:1144820648
Name:COMMUNITY WELLNESS GROUP LLC
Entity type:Organization
Organization Name:COMMUNITY WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLYN
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:GARRETT-WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LCPC
Authorized Official - Phone:773-320-9592
Mailing Address - Street 1:635 ARGYLE AVE
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-1201
Mailing Address - Country:US
Mailing Address - Phone:773-844-8813
Mailing Address - Fax:
Practice Address - Street 1:635 ARGYLE AVE
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-1201
Practice Address - Country:US
Practice Address - Phone:773-844-8813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-26
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL19002Medicaid