MEDICARE: HUMBOLDT PARK COUNSELING, 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	:	1750995650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUMBOLDT PARK COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	3446 W HIRSCH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60651-2314
Country	:	US
Telephone Number	:	312-620-0408
Fax Number	:

Provider Business Practice Location Address
First Line	:	938 N CALIFORNIA AVE
Second Line	:	COMMERCIAL UNIT
City	:	CHICAGO
State	:	IL
Zip	:	60622-1435
Country	:	US
Telephone Number	:	312-620-0408
Fax Number	:

Authorized Official
Title or Position	:	OWNER, PSYCHOTHERAPIST
Name	:	CAROLYN SELLERS
Credential	:	LCSW
Telephone Number	:	312-620-0408

Provider Enumeration Date	:	09/08/2020
Last Update Date	:	10/15/2021

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