Healthcare Provider Details

I. General information

NPI: 1316658487
Provider Name (Legal Business Name): CHICAGOLAND PROFESSIONAL THERAPY GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2656 W MONTROSE AVE FL 2
CHICAGO IL
60618-1559
US

IV. Provider business mailing address

2656 W MONTROSE AVE FL 2
CHICAGO IL
60618-1559
US

V. Phone/Fax

Practice location:
  • Phone: 314-882-1126
  • Fax:
Mailing address:
  • Phone: 314-882-1126
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. ELIZABETH HALL
Title or Position: PRESIDENT OF OPERATIONS
Credential: MSW, MBA
Phone: 314-882-1126