1336759620 NPI number — TELOS HEALTH AND WELLNESS SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336759620 NPI number — TELOS HEALTH AND WELLNESS SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TELOS HEALTH AND WELLNESS SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336759620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2005 N. PROSPECT AVE PMB 1178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822-1235
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-292-7262
Provider Business Mailing Address Fax Number:
217-209-5798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 N CHESTNUT ST.
Provider Second Line Business Practice Location Address:
STE 235
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-292-7262
Provider Business Practice Location Address Fax Number:
217-209-5798
Provider Enumeration Date:
08/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
MARISSA
Authorized Official Middle Name:
JONAL
Authorized Official Title or Position:
CLINICAL COUNSELOR
Authorized Official Telephone Number:
217-898-5160

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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