Healthcare Provider Details

I. General information

NPI: 1770065088
Provider Name (Legal Business Name): NOURISH PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 OLD ORCHARD RD STE 29
SKOKIE IL
60077-1027
US

IV. Provider business mailing address

5225 OLD ORCHARD RD STE 29
SKOKIE IL
60077-1027
US

V. Phone/Fax

Practice location:
  • Phone: 773-403-2374
  • Fax:
Mailing address:
  • Phone: 773-403-2374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.007420
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018995
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.013079
License Number StateIL

VIII. Authorized Official

Name: LINNET MENDEZ
Title or Position: PRACTICE MANAGER
Credential: LCPC
Phone: 773-403-2374