Healthcare Provider Details

I. General information

NPI: 1972095891
Provider Name (Legal Business Name): EXPLORE YOUR TRUTH INCOPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 W JACKSON BLVD
CHICAGO IL
60607-2914
US

IV. Provider business mailing address

10117 S MORGAN ST
CHICAGO IL
60643-2222
US

V. Phone/Fax

Practice location:
  • Phone: 773-609-0307
  • Fax:
Mailing address:
  • Phone: 773-655-4544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number180-005424
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number180005424
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number180005424
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number180005424
License Number StateIL

VIII. Authorized Official

Name: LISA N HOPKINS
Title or Position: CEO / PRESIDENT
Credential: LCPC
Phone: 773-655-4544