Healthcare Provider Details

I. General information

NPI: 1538946819
Provider Name (Legal Business Name): CHRYSALIS WELLNESS AND CONSULTING GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 N SANGAMON ST STE 200
CHICAGO IL
60607-2201
US

IV. Provider business mailing address

159 N SANGAMON ST STE 200
CHICAGO IL
60607-2201
US

V. Phone/Fax

Practice location:
  • Phone: 312-799-9810
  • Fax: 312-500-0409
Mailing address:
  • Phone: 312-799-9810
  • Fax: 312-500-0409

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: VIVIAN MOORE
Title or Position: LCPC
Credential:
Phone: 312-799-9810