Healthcare Provider Details

I. General information

NPI: 1669144218
Provider Name (Legal Business Name): IMAGINE THERAPY MINDFULNESS HEALING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W GRAND AVE
CHICAGO IL
60654
US

IV. Provider business mailing address

708 W GRAND AVE
CHICAGO IL
60654
US

V. Phone/Fax

Practice location:
  • Phone: 312-300-2190
  • Fax:
Mailing address:
  • Phone: 312-300-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CHRISSA FLANNERY
Title or Position: MANAGER
Credential:
Phone: 708-337-0642