Healthcare Provider Details

I. General information

NPI: 1912549676
Provider Name (Legal Business Name): MIND CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 N RAVENSWOOD AVE STE 225
CHICAGO IL
60640-5802
US

IV. Provider business mailing address

4411 N RAVENSWOOD AVE STE 225
CHICAGO IL
60640-5802
US

V. Phone/Fax

Practice location:
  • Phone: 312-667-3775
  • Fax:
Mailing address:
  • Phone: 312-667-3775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DAVID A MEYERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 312-667-3775