MEDICARE: HOLDING SPACE FOR PSYCHOLOGICAL WELLNESS, 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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1184271231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLDING SPACE FOR PSYCHOLOGICAL WELLNESS, LLC

Provider Business Mailing Address
First Line	:	6601 N AVONDALE AVE FL 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1572
Country	:	US
Telephone Number	:	773-796-7035
Fax Number	:

Provider Business Practice Location Address
First Line	:	6601 N AVONDALE AVE FL 2
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60631-1572
Country	:	US
Telephone Number	:	773-796-7035
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PATRICIA M VILLARREAL
Credential	:	PSY.D.
Telephone Number	:	773-796-7035

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	06/02/2026

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