Healthcare Provider Details

I. General information

NPI: 1629809181
Provider Name (Legal Business Name): THERAPY OVER EASY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 09/22/2024
Certification Date: 09/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3610 216TH ST
MATTESON IL
60443-2713
US

IV. Provider business mailing address

3610 216TH ST
MATTESON IL
60443-2713
US

V. Phone/Fax

Practice location:
  • Phone: 708-925-4321
  • Fax:
Mailing address:
  • Phone: 708-925-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LORYN KIMBROUGH
Title or Position: OWNER
Credential: LCPC
Phone: 708-925-4321