Healthcare Provider Details

I. General information

NPI: 1467166009
Provider Name (Legal Business Name): REDEFINE PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 W DAKIN STREET
CHICAGO IL
60613
US

IV. Provider business mailing address

924 W DAKIN ST
CHICAGO IL
60613-3093
US

V. Phone/Fax

Practice location:
  • Phone: 773-796-7072
  • 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 Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SARAH FORSYTHE
Title or Position: CEO
Credential:
Phone: 737-967-0727