| NPI | 1164263893 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LATINA RUSSELL Credentialing Specialist 312-663-1130 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2024-06-05 |
| Last Update Date | 2024-09-26 |