Healthcare Provider Details

I. General information

NPI: 1417725276
Provider Name (Legal Business Name): H14 LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6825 167TH ST
TINLEY PARK IL
60477-2501
US

IV. Provider business mailing address

2045 W GRAND AVE STE B
CHICAGO IL
60612-1577
US

V. Phone/Fax

Practice location:
  • Phone: 708-465-0150
  • Fax:
Mailing address:
  • Phone:
  • 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 Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: MALACHI KELLY
Title or Position: OWNER
Credential: LCPC
Phone: 708-465-0150