Healthcare Provider Details

I. General information

NPI: 1790096667
Provider Name (Legal Business Name): CATHERINE HOUSE CLINCIAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4314 S COTTAGE GROVE AVE SUITE 208
CHICAGO IL
60653-3514
US

IV. Provider business mailing address

4314 S COTTAGE GROVE AVE SUITE 208
CHICAGO IL
60653-3514
US

V. Phone/Fax

Practice location:
  • Phone: 312-747-0036
  • Fax: 312-747-2208
Mailing address:
  • Phone: 312-747-0036
  • Fax: 312-747-2208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25901
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: