Healthcare Provider Details

I. General information

NPI: 1326722950
Provider Name (Legal Business Name): MY THERAPIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 06/14/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 CAMPBELL DR
GURNEE IL
60031-3112
US

IV. Provider business mailing address

915 CAMPBELL DR
GURNEE IL
60031-3112
US

V. Phone/Fax

Practice location:
  • Phone: 224-440-2665
  • Fax:
Mailing address:
  • Phone: 224-440-2665
  • 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: SAIRA KHAN
Title or Position: MENTAL HEALTH THERAPIST
Credential: LCPC
Phone: 224-440-2665