Healthcare Provider Details

I. General information

NPI: 1306394416
Provider Name (Legal Business Name): MOVE THERAPY AND WELLNESS 1241 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2016
Last Update Date: 09/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3808 N ASHLAND AVE COMMERCIAL CONDO
CHICAGO IL
60613-5382
US

IV. Provider business mailing address

3808 N ASHLAND AVE COMMERCIAL CONDO
CHICAGO IL
60613-5382
US

V. Phone/Fax

Practice location:
  • Phone: 312-217-5887
  • Fax:
Mailing address:
  • Phone: 312-217-5887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LAURA MARIA ISABEL DZIEKIEWICZ
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 312-217-5887