Healthcare Provider Details

I. General information

NPI: 1326545773
Provider Name (Legal Business Name): HEALTHY SOUL TALK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S 1ST AVE STE 307
MAYWOOD IL
60153-2419
US

IV. Provider business mailing address

1701 S 1ST AVE STE 307
MAYWOOD IL
60153-2419
US

V. Phone/Fax

Practice location:
  • Phone: 708-483-8455
  • Fax: 708-776-4717
Mailing address:
  • Phone: 708-483-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. KIMBERLY THOMAS
Title or Position: PRINCIPLE OWNER
Credential: LCPC
Phone: 708-483-8455