Healthcare Provider Details

I. General information

NPI: 1942916572
Provider Name (Legal Business Name): 360 TALK THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 76TH ST STE 303
CHICAGO IL
60620-1640
US

IV. Provider business mailing address

400 W 76TH ST STE 303
CHICAGO IL
60620-1640
US

V. Phone/Fax

Practice location:
  • Phone: 888-338-6232
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY L WILKES
Title or Position: CEO
Credential: FNP
Phone: 773-437-7816