Healthcare Provider Details

I. General information

NPI: 1720745912
Provider Name (Legal Business Name): FLY RADICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2659 W DIVISION ST
CHICAGO IL
60622-2851
US

IV. Provider business mailing address

1711 W JARVIS AVE
CHICAGO IL
60626-1600
US

V. Phone/Fax

Practice location:
  • Phone: 773-469-0709
  • Fax:
Mailing address:
  • Phone: 773-469-0709
  • 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: DORIAN A. ORTEGA
Title or Position: PSYCHOTHERAPIST/ OWNER
Credential: LCPC
Phone: 773-469-0709