Healthcare Provider Details

I. General information

NPI: 1679207682
Provider Name (Legal Business Name): URBAN SUMMIT PSYCHOTHERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 W DIVERSEY PKWY APT 302
CHICAGO IL
60614-9412
US

IV. Provider business mailing address

1921 W DIVERSEY PKWY APT 302
CHICAGO IL
60614-9412
US

V. Phone/Fax

Practice location:
  • Phone: 773-984-4762
  • Fax:
Mailing address:
  • Phone: 773-984-4762
  • 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: ERIKA OSTRANDER
Title or Position: CEO
Credential: LCPC
Phone: 773-984-4762