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General NPI Number Information
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NPI Number | 1124530456
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Entity Type | Organization
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Legal Business Name | FOUNDATIONS COUNSELING, LLC
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Dates
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Enumeration Date | 10/26/2017
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Last Update Date | 07/20/2018
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Provider Practice Location Address
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Address Line | 9730 S WESTERN AVE STE 215
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City | EVERGREEN PARK
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State | IL
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Zip | 60805
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Country | US
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Telephone | 773-242-9726
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Fax |
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Provider Business Mailing Address
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Address Line | 9730 S WESTERN AVE STE 215
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City | EVERGREEN PARK
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State | IL
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Zip | 60805-2871
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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 | CEO/ MENTAL HEALTH THERAPIST
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Name | SAMANTHA LOUISE ALLEN
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Credential | MSW, LCSW
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Telephone | 708-529-0122
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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 | 149019762
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License Number State | IL
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