Healthcare Provider Details

I. General information

NPI: 1518502251
Provider Name (Legal Business Name): THERAPY STUDIO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 W DIVISION ST
COAL CITY IL
60416-1581
US

IV. Provider business mailing address

295 W DIVISION ST
COAL CITY IL
60416-1581
US

V. Phone/Fax

Practice location:
  • Phone: 815-515-0010
  • Fax: 708-590-0759
Mailing address:
  • Phone: 815-515-0010
  • Fax: 708-590-0759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TRACY STONE
Title or Position: OWNER
Credential: LCPC
Phone: 708-906-5246