MEDICARE: PATHOS, INC.

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	101YP2500X	Professional Counselor		IL

General Provider Information

NPI Number	:	1881725919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHOS, INC.

Provider Business Mailing Address
First Line	:	1700 W IRVING PARK RD
Second Line	:	SUITE 108
City	:	CHICAGO
State	:	IL
Zip	:	60613-2559
Country	:	US
Telephone Number	:	773-562-1388
Fax Number	:	773-435-1133

Provider Business Practice Location Address
First Line	:	1700 W IRVING PARK RD
Second Line	:	SUITE 108
City	:	CHICAGO
State	:	IL
Zip	:	60613-2559
Country	:	US
Telephone Number	:	773-562-1388
Fax Number	:	773-435-1133

Authorized Official
Title or Position	:	ART THERAPIST, LICENSED COUNSELOR
Name	:	MISS LAURA ANN JACOB
Credential	:	MAAT, LCPC
Telephone Number	:	773-562-1388

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/22/2020

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