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NPI Code Detail

MEDICARE: MOVE THERAPY AND WELLNESS 1241 LLC

MEDICARE: MOVE THERAPY AND WELLNESS 1241 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
1133NN1002XNutrition Education Nutritionist
21041C0700XClinical Social Worker

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11508105826OTHERILBCBS

General Provider Information

NPI Number : 1306394416
Entity Type Code : Organization
Provider Name (Legal Business Name) : MOVE THERAPY AND WELLNESS 1241 LLC
Provider Business Mailing Address
First Line : 3808 N ASHLAND AVE
Second Line : COMMERCIAL CONDO
City : CHICAGO
State : IL
Zip : 60613-5382
Country : US
Telephone Number : 312-217-5887
Fax Number :
Provider Business Practice Location Address
First Line : 3808 N ASHLAND AVE
Second Line : COMMERCIAL CONDO
City : CHICAGO
State : IL
Zip : 60613-5382
Country : US
Telephone Number : 312-217-5887
Fax Number :
Authorized Official
Title or Position : OWNER/PSYCHOTHERAPIST
Name : LAURA MARIA ISABEL DZIEKIEWICZ
Credential : LCSW
Telephone Number : 312-217-5887
Provider Enumeration Date : 09/17/2016
Last Update Date : 09/17/2016

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