Healthcare Provider Details

I. General information

NPI: 1932687332
Provider Name (Legal Business Name): GRACEFUL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MAIN ST STE 203
OSWEGO IL
60543-8593
US

IV. Provider business mailing address

113 MAIN ST STE 203
OSWEGO IL
60543-8593
US

V. Phone/Fax

Practice location:
  • Phone: 630-733-9108
  • Fax: 630-912-4242
Mailing address:
  • Phone: 630-733-9108
  • Fax: 630-912-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.001164
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN FISH
Title or Position: OWNER & THERAPIST
Credential: LMFT
Phone: 630-733-9108