Healthcare Provider Details

I. General information

NPI: 1023284726
Provider Name (Legal Business Name): MIDWEST THERAPY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E LAKE ST SUITE 106
BLOOMINGDALE IL
60108-1179
US

IV. Provider business mailing address

889 ASBURY LN
SCHAUMBURG IL
60193-4101
US

V. Phone/Fax

Practice location:
  • Phone: 630-290-3384
  • Fax:
Mailing address:
  • Phone: 630-290-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004492
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166-000532
License Number StateIL

VIII. Authorized Official

Name: DR. SARA BRANDT
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 630-290-3384