MEDICARE: ELEVATED PERSPECTIVE PSYCHOTHERAPY, PLLC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1174297436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATED PERSPECTIVE PSYCHOTHERAPY, PLLC

Provider Business Mailing Address
First Line	:	1523 W AUGUSTA BLVD APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-5625
Country	:	US
Telephone Number	:	231-690-5306
Fax Number	:

Provider Business Practice Location Address
First Line	:	1523 W AUGUSTA BLVD APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60642-5625
Country	:	US
Telephone Number	:	231-690-5306
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	ELYSE SOMERS ROCCO
Credential	:	PSYD
Telephone Number	:	231-690-5306

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	08/02/2021

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