Healthcare Provider Details

I. General information

NPI: 1215697974
Provider Name (Legal Business Name): RESTORATIVE COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 W MONTROSE AVE STE 307
CHICAGO IL
60618-1561
US

IV. Provider business mailing address

1321 UPLAND DR # 6900
HOUSTON TX
77043-4718
US

V. Phone/Fax

Practice location:
  • Phone: 773-217-9249
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: TIA COCHRAN
Title or Position: CO-OWNER
Credential:
Phone: 314-620-9148