Healthcare Provider Details

I. General information

NPI: 1487178018
Provider Name (Legal Business Name): MICHELLE HORNER PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N RAVENSWOOD AVE STE C
CHICAGO IL
60640-4408
US

IV. Provider business mailing address

661 W LAKE ST STE 2S
CHICAGO IL
60661-1034
US

V. Phone/Fax

Practice location:
  • Phone: 773-754-7441
  • Fax:
Mailing address:
  • Phone: 312-834-4245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071010070
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071010070
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: