Healthcare Provider Details

I. General information

NPI: 1851959357
Provider Name (Legal Business Name): A BEAUTIFUL MIND, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 S HARPER AVE # 2C
CHICAGO IL
60615-4119
US

IV. Provider business mailing address

5113 S HARPER AVE # 2C
CHICAGO IL
60615-4119
US

V. Phone/Fax

Practice location:
  • Phone: 773-304-3699
  • Fax:
Mailing address:
  • Phone: 773-304-3699
  • Fax: 773-304-4555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
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: CHIQUITA LEE
Title or Position: CEO
Credential:
Phone: 773-304-3699