Healthcare Provider Details

I. General information

NPI: 1144034356
Provider Name (Legal Business Name): MODERN THERAPY ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2966 N OAKLEY AVE
CHICAGO IL
60618-8010
US

IV. Provider business mailing address

2966 N OAKLEY AVE
CHICAGO IL
60618-8010
US

V. Phone/Fax

Practice location:
  • Phone: 312-508-8748
  • Fax:
Mailing address:
  • Phone: 312-508-8748
  • 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: ERIK GILES
Title or Position: OWNER THERAPIST
Credential: LCSW
Phone: 312-270-7743