Healthcare Provider Details

I. General information

NPI: 1316747538
Provider Name (Legal Business Name): NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 N RAVENSWOOD AVE STE 208
CHICAGO IL
60640-1710
US

IV. Provider business mailing address

5100 N RAVENSWOOD AVE STE 208
CHICAGO IL
60640-1710
US

V. Phone/Fax

Practice location:
  • Phone: 773-791-0469
  • Fax:
Mailing address:
  • Phone: 773-791-0469
  • 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: JOSHUA SMITH HETHERINGTON
Title or Position: CEO
Credential: LMFT, LCPC
Phone: 773-791-0469