Healthcare Provider Details

I. General information

NPI: 1669964482
Provider Name (Legal Business Name): FERMATA PSYCHOTHERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 W JACKSON BLVD STE 1450
CHICAGO IL
60604-3535
US

IV. Provider business mailing address

53 W JACKSON BLVD STE 1632
CHICAGO IL
60604-3734
US

V. Phone/Fax

Practice location:
  • Phone: 312-725-6192
  • Fax:
Mailing address:
  • Phone: 312-520-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019286
License Number StateIL

VIII. Authorized Official

Name: SANTIAGO DELBOY
Title or Position: PRESIDENT
Credential:
Phone: 312-520-6096