=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073312351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESILIENT MENTAL HEALTH & WELLNESS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2025
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8543 S STONY ISLAND AVE STE 3
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-380-9808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11713 S MAPLEWOOD AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60655-1524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-380-9808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DERICK JOHNSON
-----------------------------------------------------
Credential | APRN, PMHNP-BC
-----------------------------------------------------
Telephone | 312-545-3187
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------