Healthcare Provider Details

I. General information

NPI: 1083463012
Provider Name (Legal Business Name): MINDFUL MOMENTS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8508 S OGLESBY AVE
CHICAGO IL
60617-2308
US

IV. Provider business mailing address

1130 S CANAL ST # 1264
CHICAGO IL
60607-4907
US

V. Phone/Fax

Practice location:
  • Phone: 773-970-4514
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TIANA DENISE HILL
Title or Position: THERAPIST
Credential: LCSW
Phone: 773-970-4514