Healthcare Provider Details

I. General information

NPI: 1245912021
Provider Name (Legal Business Name): LONGBOARDERS LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 E MADISON ST STE 1603A
CHICAGO IL
60603-3095
US

IV. Provider business mailing address

67 E MADISON ST STE 1603A
CHICAGO IL
60603-3095
US

V. Phone/Fax

Practice location:
  • Phone: 847-372-1593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TAYLOR ANN MOORE
Title or Position: FOUNDER, DIRECTOR
Credential: LCPC
Phone: 847-372-1593