Healthcare Provider Details

I. General information

NPI: 1780407189
Provider Name (Legal Business Name): MINDFUL BEHAVIOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6815 W 63RD ST
CHICAGO IL
60638-4048
US

IV. Provider business mailing address

PO BOX 388556
CHICAGO IL
60638-8556
US

V. Phone/Fax

Practice location:
  • Phone: 708-304-3010
  • Fax: 708-575-5333
Mailing address:
  • Phone: 708-304-3010
  • Fax: 708-575-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELISA JULIA LEE
Title or Position: CEO/OWNER
Credential: LCPC
Phone: 708-202-9151