Healthcare Provider Details

I. General information

NPI: 1154915122
Provider Name (Legal Business Name): SERENITY SHIELD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2021
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 E ERIE ST APT 2712
CHICAGO IL
60611-6211
US

IV. Provider business mailing address

2 E ERIE ST
CHICAGO IL
60611-2724
US

V. Phone/Fax

Practice location:
  • Phone: 708-657-5043
  • Fax: 312-643-1187
Mailing address:
  • Phone: 708-657-5043
  • Fax: 312-643-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. DERRICK JAMES JOHNSON
Title or Position: VICE PRESIDENT
Credential: PSY.D
Phone: 708-657-5043