Organization
THRIVE MENTAL WELLNESS, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COURTNEY NICOLLE FORMAN (OWNER)
(815) 209-8486
Entity
Organization
Contact information
Practice address
13508 JULIE DR, POPLAR GROVE, IL 61065-7829
(815) 596-0098
Mailing address
13508 JULIE DR, POPLAR GROVE, IL 61065-7829
(815) 596-0098
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1376099127
OTHER
IL
Enumeration date
04/23/2025
Last updated
04/27/2025
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