Healthcare Provider Details

I. General information

NPI: 1538875687
Provider Name (Legal Business Name): RADICAL AUTHENTICITY & WELLNESS PSYCHOTHERAPY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 W HOLLYWOOD AVE
CHICAGO IL
60660-4399
US

IV. Provider business mailing address

5754 N WINTHROP AVE APT 3
CHICAGO IL
60660-5148
US

V. Phone/Fax

Practice location:
  • Phone: 434-284-3806
  • Fax:
Mailing address:
  • Phone: 434-284-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER K TATUM
Title or Position: PRESIDENT
Credential: PHD
Phone: 434-284-3806