MEDICARE: LIGHT SIDE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1003537341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT SIDE THERAPY LLC

Provider Business Mailing Address
First Line	:	1845 E RAND RD STE L109
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-4375
Country	:	US
Telephone Number	:	773-490-8863
Fax Number	:

Provider Business Practice Location Address
First Line	:	1845 E RAND RD STE L109
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-4375
Country	:	US
Telephone Number	:	773-490-8863
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	CAROL REGENHARDT
Credential	:
Telephone Number	:	773-490-8863

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	09/06/2022

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Directions to “LIGHT SIDE THERAPY LLC ” Practice Location

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