Healthcare Provider Details

I. General information

NPI: 1043678246
Provider Name (Legal Business Name): CODY FOURNIER LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 N MICHIGAN AVE
CHICAGO IL
60601-7757
US

IV. Provider business mailing address

283 WILLIAMS CROSSING RD
COVENTRY RI
02827-1531
US

V. Phone/Fax

Practice location:
  • Phone: 774-214-8076
  • Fax:
Mailing address:
  • Phone: 774-214-8076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126216
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: