Healthcare Provider Details

I. General information

NPI: 1750995650
Provider Name (Legal Business Name): HUMBOLDT PARK COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 10/15/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 N CALIFORNIA AVE COMMERCIAL UNIT
CHICAGO IL
60622-1435
US

IV. Provider business mailing address

3446 W HIRSCH ST
CHICAGO IL
60651-2314
US

V. Phone/Fax

Practice location:
  • Phone: 312-620-0408
  • Fax:
Mailing address:
  • Phone: 312-620-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN SELLERS
Title or Position: OWNER, PSYCHOTHERAPIST
Credential: LCSW
Phone: 312-620-0408