Healthcare Provider Details

I. General information

NPI: 1407491863
Provider Name (Legal Business Name): ELEVATED GROUPS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 08/28/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10436 SOUTHWEST HWY
CHICAGO RIDGE IL
60415-2282
US

IV. Provider business mailing address

10436 SOUTHWEST HWY
CHICAGO RIDGE IL
60415-2282
US

V. Phone/Fax

Practice location:
  • Phone: 708-444-0304
  • Fax:
Mailing address:
  • Phone: 708-444-0304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMED TARAWNEH
Title or Position: OWNER
Credential:
Phone: 708-647-3333