Healthcare Provider Details

I. General information

NPI: 1770338089
Provider Name (Legal Business Name): COLIBERATE USA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2024
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MADISON ST
CHICAGO IL
60606-3414
US

IV. Provider business mailing address

9449 S KEDZIE AVE # 331
EVERGREEN PARK IL
60805-2325
US

V. Phone/Fax

Practice location:
  • Phone: 312-210-0965
  • Fax:
Mailing address:
  • Phone: 312-210-0965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: NOEL C GREEN
Title or Position: AUTHORIZED REPRESENTATIVE
Credential: LSW
Phone: 312-818-0497