Healthcare Provider Details

I. General information

NPI: 1619767811
Provider Name (Legal Business Name): DRIVE PSYCHOTHERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2025
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4619 N RAVENSWOOD AVE # 104-D
CHICAGO IL
60640-4580
US

IV. Provider business mailing address

4619 N RAVENSWOOD AVE STE 104-D
CHICAGO IL
60640-4580
US

V. Phone/Fax

Practice location:
  • Phone: 847-933-0051
  • Fax:
Mailing address:
  • Phone: 901-482-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT FOREMAN
Title or Position: CREDENTIALING
Credential:
Phone: 630-313-0069