Healthcare Provider Details

I. General information

NPI: 1972313922
Provider Name (Legal Business Name): RADIANT THERAPY AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2025
Last Update Date: 01/11/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 LAKE ST STE 210
OAK PARK IL
60301-1137
US

IV. Provider business mailing address

2124 NEWCASTLE AVE
WESTCHESTER IL
60154-4453
US

V. Phone/Fax

Practice location:
  • Phone: 708-663-1214
  • Fax:
Mailing address:
  • Phone: 708-663-1214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ANN OH
Title or Position: CO OWNER
Credential:
Phone: 708-663-1214