=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104468800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMOTION-FOCUSED THERAPY CHICAGO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2019
-----------------------------------------------------
Last Update Date | 10/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 E OHIO ST STE 405
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-5288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-592-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2423 W HURON ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-1684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-592-1615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. RHONDA GOLDMAN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 773-592-1615
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------