Healthcare Provider Details

I. General information

NPI: 1205168424
Provider Name (Legal Business Name): INTERTWINED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2010
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10540 S WESTERN AVE STE 103
CHICAGO IL
60643-2541
US

IV. Provider business mailing address

10540 S WESTERN AVE STE 103
CHICAGO IL
60643-2541
US

V. Phone/Fax

Practice location:
  • Phone: 708-499-2030
  • Fax:
Mailing address:
  • Phone: 708-499-2030
  • Fax: 708-634-3688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180005742
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149011142
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. ROCHELLE JOHNSON
Title or Position: OWNER
Credential: LCSW
Phone: 708-499-2030