Healthcare Provider Details

I. General information

NPI: 1245933704
Provider Name (Legal Business Name): WOODSTOCK THERAPIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PYOTT RD STE 101
LAKE IN THE HILLS IL
60156-9795
US

IV. Provider business mailing address

1301 PYOTT RD STE 101
LAKE IN THE HILLS IL
60156-9795
US

V. Phone/Fax

Practice location:
  • Phone: 815-236-3272
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LINDSAY KEISMAN
Title or Position: DIRECTOR
Credential:
Phone: 815-236-3272