Healthcare Provider Details

I. General information

NPI: 1104439413
Provider Name (Legal Business Name): MIVA PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 10/03/2020
Certification Date: 10/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 DUNHAM RD STE 1E
ST CHARLES IL
60174-1498
US

IV. Provider business mailing address

590 E THORNDALE LN
SOUTH ELGIN IL
60177-3205
US

V. Phone/Fax

Practice location:
  • Phone: 331-276-2355
  • Fax:
Mailing address:
  • Phone: 630-674-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: AYAOVI ESENAM AMEZOTCHI
Title or Position: THERAPIST
Credential:
Phone: 630-674-2405