Healthcare Provider Details

I. General information

NPI: 1154258101
Provider Name (Legal Business Name): GEORGIA BOXER THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

938 EDGEMERE CT
EVANSTON IL
60202-1429
US

IV. Provider business mailing address

938 EDGEMERE CT
EVANSTON IL
60202-1429
US

V. Phone/Fax

Practice location:
  • Phone: 773-245-3625
  • Fax:
Mailing address:
  • Phone: 773-245-3625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GEORGIA BOXER
Title or Position: PSYCHOTHERAPIST, OWNER/OPERATOR
Credential: LCPC
Phone: 773-245-3625