Healthcare Provider Details

I. General information

NPI: 1215656970
Provider Name (Legal Business Name): MENDING HEARTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 S LAURA LN
DIAMOND IL
60416-9314
US

IV. Provider business mailing address

815 S LAURA LN
DIAMOND IL
60416-9314
US

V. Phone/Fax

Practice location:
  • Phone: 630-309-0926
  • Fax:
Mailing address:
  • Phone: 630-309-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER L LOUGHRAN
Title or Position: LCSW
Credential: LCSW
Phone: 630-309-0926