Healthcare Provider Details

I. General information

NPI: 1568069128
Provider Name (Legal Business Name): ELEVATE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 01/03/2021
Certification Date: 01/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1564 N DAMEN AVE STE 208
CHICAGO IL
60622-2102
US

IV. Provider business mailing address

1564 N DAMEN AVE STE 208
CHICAGO IL
60622-2102
US

V. Phone/Fax

Practice location:
  • Phone: 217-512-0346
  • Fax:
Mailing address:
  • Phone: 217-512-0346
  • 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: RALIAT Q ADEBOYEJO
Title or Position: LICENSED THERAPIST/OWNER
Credential: LCPC
Phone: 217-512-0346