Healthcare Provider Details

I. General information

NPI: 1568197531
Provider Name (Legal Business Name): EMBODIED PRACTICE THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 SHERMAN AVE APT 3
EVANSTON IL
60202-4357
US

IV. Provider business mailing address

751 SHERMAN AVE APT 3
EVANSTON IL
60202-4357
US

V. Phone/Fax

Practice location:
  • Phone: 845-886-4585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHEL E HUDGENS
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 847-868-4585