Healthcare Provider Details

I. General information

NPI: 1184497893
Provider Name (Legal Business Name): MOXIE AND GRACE THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W SURF ST
CHICAGO IL
60657-6106
US

IV. Provider business mailing address

1440 W TAYLOR ST # 1076
CHICAGO IL
60607-4623
US

V. Phone/Fax

Practice location:
  • Phone: 480-239-8934
  • Fax:
Mailing address:
  • Phone: 773-873-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JESSICA COORS
Title or Position: PSYCHOTHERAPIST
Credential: LCPC
Phone: 773-873-7688