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General NPI Number Information
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NPI Number | 1104425552
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Entity Type | Organization
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Legal Business Name | FIFTH STAR COLLECTIVE, LLC
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Dates
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Enumeration Date | 10/17/2020
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Last Update Date | 11/13/2020
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Provider Practice Location Address
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Address Line | 2711 N LAWNDALE AVE UNIT 2
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City | CHICAGO
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State | IL
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Zip | 60647-1127
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Country | US
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Telephone | 720-982-9038
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Fax |
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Provider Business Mailing Address
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Address Line | 3914 W ALTGELD ST # 2E
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City | CHICAGO
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State | IL
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Zip | 60647-1004
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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 | CO-FOUNDER, SENIOR CONSULTANT
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Name | MR. CONNOR WILLIAMS
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Credential |
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Telephone | 720-982-9038
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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