1558184465 NPI number — MINDFUL WELLNESS COUNSELING GROUP

Table of content: PAUL JOSEPH MCKENNA JR. DMD (NPI 1013121953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558184465 NPI number — MINDFUL WELLNESS COUNSELING GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDFUL WELLNESS COUNSELING GROUP
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:
1558184465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 RIDGE RD STE 1SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOMEWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60430-1934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-637-1672
Provider Business Mailing Address Fax Number:
708-637-1633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 RIDGE RD STE 1SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOMEWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60430-1934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-637-1672
Provider Business Practice Location Address Fax Number:
708-637-1633
Provider Enumeration Date:
11/07/2024

Additional Information

Authorized Official

Authorized Official Last Name:
NORTHERN
Authorized Official First Name:
SEKAI
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
772-453-1896

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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