Provider Demographics
NPI:1871117887
Name:RESTORE WELLNESS COUNSELING LLC
Entity type:Organization
Organization Name:RESTORE WELLNESS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICHELE
Authorized Official - Middle Name:DEANNE
Authorized Official - Last Name:HAWBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-972-0744
Mailing Address - Street 1:106 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62523-1207
Mailing Address - Country:US
Mailing Address - Phone:779-220-0441
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62523
Practice Address - Country:US
Practice Address - Phone:779-220-0441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407097264OtherNPI 1