Healthcare Provider Details

I. General information

NPI: 1558606590
Provider Name (Legal Business Name): MUSIC INSTITUTE OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 SHERMAN AVE
EVANSTON IL
60201-3713
US

IV. Provider business mailing address

1702 SHERMAN AVE
EVANSTON IL
60201-3713
US

V. Phone/Fax

Practice location:
  • Phone: 847-425-9708
  • Fax:
Mailing address:
  • Phone: 847-425-9708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberOH.008588
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MARNI BERTHA ROSEN
Title or Position: PRACTICE MANAGER
Credential: PSY.D
Phone: 847-448-8336