Healthcare Provider Details

I. General information

NPI: 1104752500
Provider Name (Legal Business Name): HAYWOOD WALTON THERAPEUTIC SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W WACKER DR
CHICAGO IL
60606-1217
US

IV. Provider business mailing address

211 W. WACKER DR SUITE 120 PMB 2460
CHICAGO IL
60606
US

V. Phone/Fax

Practice location:
  • Phone: 312-612-9375
  • Fax:
Mailing address:
  • Phone: 312-612-9375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. LATOSHA KAMILLE HAYWOOD
Title or Position: OWNER
Credential: LCPC
Phone: 312-612-9375