Healthcare Provider Details

I. General information

NPI: 1679308787
Provider Name (Legal Business Name): ELEVATION INDIVIDUAL AND FAMILY THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 SOUTHWICK DR STE 600
MATTESON IL
60443-2281
US

IV. Provider business mailing address

4801 SOUTHWICK DR STE 600
MATTESON IL
60443-2281
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-8864
  • Fax:
Mailing address:
  • Phone: 708-300-8864
  • 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: TIONNA HARRIS
Title or Position: CEO
Credential: MSW, LCSW
Phone: 708-300-8864