MEDICARE: THE CHICAGO HEALING COLLECTIVE, 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1255068110
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CHICAGO HEALING COLLECTIVE, LLC

Provider Business Mailing Address
First Line	:	3054 N CLIFTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4334
Country	:	US
Telephone Number	:	312-714-9414
Fax Number	:

Provider Business Practice Location Address
First Line	:	3054 N CLIFTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-4334
Country	:	US
Telephone Number	:	312-714-9414
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST/OWNER
Name	:	ELIZABETH DIAZ
Credential	:	LCSW
Telephone Number	:	312-714-9414

Provider Enumeration Date	:	08/02/2022
Last Update Date	:	08/02/2022

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