Healthcare Provider Details

I. General information

NPI: 1922927680
Provider Name (Legal Business Name): CHACE WALL PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 N ASHLAND AVE
CHICAGO IL
60657-0195
US

IV. Provider business mailing address

3322 N ASHLAND AVE
CHICAGO IL
60657-0195
US

V. Phone/Fax

Practice location:
  • Phone: 312-569-0556
  • Fax:
Mailing address:
  • Phone: 312-569-0556
  • 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: CHACE WALL
Title or Position: PRESIDENT
Credential: LCPC
Phone: 312-569-0556