Healthcare Provider Details

I. General information

NPI: 1770049462
Provider Name (Legal Business Name): CHICAGO GROWTH MINDSET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 N CICERO AVE
CHICAGO IL
60641-5110
US

IV. Provider business mailing address

3111 N CICERO AVE
CHICAGO IL
60641-5110
US

V. Phone/Fax

Practice location:
  • Phone: 773-641-1321
  • Fax:
Mailing address:
  • Phone: 773-641-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: NILSA RUIZ
Title or Position: CO-OWNER
Credential: LCSW
Phone: 773-641-1321