Healthcare Provider Details

I. General information

NPI: 1508564667
Provider Name (Legal Business Name): NEW LEAF PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5338 N WINTHROP AVE APT 3W
CHICAGO IL
60640-2335
US

IV. Provider business mailing address

5338 N WINTHROP AVE APT 3W
CHICAGO IL
60640-2335
US

V. Phone/Fax

Practice location:
  • Phone: 248-977-9272
  • Fax:
Mailing address:
  • Phone: 248-977-9272
  • 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: AMANDA WALKER
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 248-977-9272