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General NPI Number Information
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NPI Number | 1023731452
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Entity Type | Organization
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Legal Business Name | INNER LENS THERAPY PLLC
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Dates
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Enumeration Date | 09/21/2022
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Last Update Date | 09/21/2022
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Provider Practice Location Address
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Address Line | 3300 W PALMER ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60647-7437
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Country | US
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Telephone | 224-733-9321
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Fax |
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Provider Business Mailing Address
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Address Line | 3300 W PALMER ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60647-7437
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | TREVOR PONTILLO
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Credential | LCSW
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Telephone | 224-733-9321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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