Healthcare Provider Details

I. General information

NPI: 1457096901
Provider Name (Legal Business Name): MONIMIA YVONNE MACBETH LCPC, R-DMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 03/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2659 W DIVISION ST
CHICAGO IL
60622-2851
US

IV. Provider business mailing address

1440 E 52ND ST APT 14E
CHICAGO IL
60615-4382
US

V. Phone/Fax

Practice location:
  • Phone: 954-732-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180013603
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: