Healthcare Provider Details

I. General information

NPI: 1578096830
Provider Name (Legal Business Name): MODERN MIND COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD SUITE 604
CHICAGO IL
60604-3606
US

IV. Provider business mailing address

53 W JACKSON BLVD SUITE 604
CHICAGO IL
60604-3606
US

V. Phone/Fax

Practice location:
  • Phone: 312-899-6232
  • Fax:
Mailing address:
  • Phone: 312-899-6232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180006232
License Number StateIL

VIII. Authorized Official

Name: COURTNEY ROLFE
Title or Position: OWNER/THERAPIST
Credential: LCPC
Phone: 312-899-6232