Healthcare Provider Details

I. General information

NPI: 1376472415
Provider Name (Legal Business Name): INNER WISDOM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3432 W DIVERSEY AVE FL 2
CHICAGO IL
60647-1221
US

IV. Provider business mailing address

3432 W DIVERSEY AVE FL 2
CHICAGO IL
60647-1221
US

V. Phone/Fax

Practice location:
  • Phone: 312-380-1747
  • Fax:
Mailing address:
  • Phone: 312-380-1747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY QUEROL
Title or Position: OWNER
Credential:
Phone: 786-325-3006