Healthcare Provider Details

I. General information

NPI: 1881164036
Provider Name (Legal Business Name): HYDE PARK CENTER FOR HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2018
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 S HARPER AVE STE 2006
CHICAGO IL
60615-4119
US

IV. Provider business mailing address

7418 S LAFAYETTE AVE
CHICAGO IL
60621-3406
US

V. Phone/Fax

Practice location:
  • Phone: 872-212-3424
  • Fax:
Mailing address:
  • Phone: 773-699-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA KUHNEN
Title or Position: CEO
Credential: LCSW
Phone: 872-212-3424