Healthcare Provider Details

I. General information

NPI: 1306249990
Provider Name (Legal Business Name): POSITIVE SOBRIETY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 N LAKE SHORE DR SUITE 800
CHICAGO IL
60611-4546
US

IV. Provider business mailing address

2300 WINDY RIDGE PARKWAY SUITE 210S
ATLANTA GA
30339
US

V. Phone/Fax

Practice location:
  • Phone: 312-642-7230
  • Fax: 312-642-7055
Mailing address:
  • Phone: 470-440-1647
  • Fax: 312-642-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberA-8526-001-A
License Number StateIL

VIII. Authorized Official

Name: TYEAST REYNOLDS
Title or Position: DIRECTOR OF RCM
Credential:
Phone: 678-813-0428