Healthcare Provider Details

I. General information

NPI: 1295371367
Provider Name (Legal Business Name): GOL RELATIONAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 12/10/2023
Certification Date: 12/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 N RAVENSWOOD AVE STE 205
CHICAGO IL
60640-7577
US

IV. Provider business mailing address

4611 N RAVENSWOOD AVE STE 205
CHICAGO IL
60640-7577
US

V. Phone/Fax

Practice location:
  • Phone: 773-366-4901
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. FATEME TARGOL HASANKHANI
Title or Position: LMFT
Credential:
Phone: 773-366-4901