Healthcare Provider Details

I. General information

NPI: 1336656453
Provider Name (Legal Business Name): CHERYL WOOTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 S SOUTH SHORE DR
CHICAGO IL
60649-1310
US

IV. Provider business mailing address

1448 E 52ND ST # 398
CHICAGO IL
60615-4122
US

V. Phone/Fax

Practice location:
  • Phone: 773-955-9760
  • Fax:
Mailing address:
  • Phone: 773-955-9760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178007636
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178007636
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: