Macomb Mental Wellness LLC

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

MACOMB MENTAL WELLNESS LLC

Practice address

210 S Randolph St
Macomb, IL 61455-3828

Phone

(217) 779-6063

NPI assigned

Nov 17, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Joseph William Proctor, PSY.D

Title

Clinical Psychologist

Phone

(217) 779-6063

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1605571200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605571200000",
    "number": "1548863194",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6482 LAKESHORE VIEW DR",
            "city": "RUSHVILLE",
            "state": "IL",
            "postal_code": "626814707",
            "telephone_number": "217-779-6063"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "210 S RANDOLPH ST",
            "city": "MACOMB",
            "state": "IL",
            "postal_code": "614553828",
            "telephone_number": "217-779-6063"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MACOMB MENTAL WELLNESS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-11-17",
        "last_updated": "2020-11-17",
        "certification_date": "2020-11-17",
        "status": "A",
        "authorized_official_last_name": "PROCTOR",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "WILLIAM",
        "authorized_official_title_or_position": "CLINICAL PSYCHOLOGIST",
        "authorized_official_telephone_number": "217-779-6063",
        "authorized_official_credential": "PSY.D"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Tanner Maksymicz

• Mental Health Clinic/Center (Including Community Mental Health Center) in Macomb, IL
• Providers in Macomb, IL by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 17, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.