=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114588183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEA MIRZA JAMES LMFT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2019
-----------------------------------------------------
Last Update Date | 07/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5215 N RAVENSWOOD AVE STE 211
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-767-7855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5215 N RAVENSWOOD AVE STE 211
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-767-7855
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SOLE MEMBER
-----------------------------------------------------
Name | CLEA JAMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-767-7855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------