Healthcare Provider Details

I. General information

NPI: 1235689662
Provider Name (Legal Business Name): NITA MARCHANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

IV. Provider business mailing address

5128 W HENDERSON ST
CHICAGO IL
60641-4242
US

V. Phone/Fax

Practice location:
  • Phone: 773-651-3629
  • Fax:
Mailing address:
  • Phone: 773-793-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25812
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number31898
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: