Healthcare Provider Details

I. General information

NPI: 1992306518
Provider Name (Legal Business Name): GRAVITY AND GRACE PSYCHOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 S MICHIGAN AVE APT 602
CHICAGO IL
60605-3398
US

IV. Provider business mailing address

1305 S MICHIGAN AVE APT 602
CHICAGO IL
60605-3398
US

V. Phone/Fax

Practice location:
  • Phone: 440-417-2514
  • Fax:
Mailing address:
  • Phone: 440-417-2514
  • 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: EDIE HITCHCOCK
Title or Position: OWNER
Credential: LPC
Phone: 440-417-2514