Healthcare Provider Details

I. General information

NPI: 1609745470
Provider Name (Legal Business Name): CONSCIOUS RESET THERAPY AND WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2025
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4334 N CLARENDON AVE APT 302
CHICAGO IL
60613-1563
US

IV. Provider business mailing address

4334 N CLARENDON AVE APT 302
CHICAGO IL
60613-1563
US

V. Phone/Fax

Practice location:
  • Phone: 703-405-5631
  • Fax:
Mailing address:
  • Phone: 703-405-5631
  • 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: MR. VINCENT HENNEBURG
Title or Position: OWNER
Credential: LCSW
Phone: 703-405-5631