Healthcare Provider Details

I. General information

NPI: 1730656000
Provider Name (Legal Business Name): EMBODIED CHANGE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2332 W FARWELL AVE APT 1E
CHICAGO IL
60645-4753
US

IV. Provider business mailing address

2332 W FARWELL AVE APT 1E
CHICAGO IL
60645-4753
US

V. Phone/Fax

Practice location:
  • Phone: 773-726-7290
  • Fax:
Mailing address:
  • Phone: 773-726-7290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MOLLIE RYAN
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCPC
Phone: 773-726-7290