=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144100561
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIDA THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2025
-----------------------------------------------------
Last Update Date | 09/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1322 W 18TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-3148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-669-7901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11606 S AVENUE G
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-7415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-669-7901
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL THERAPIST
-----------------------------------------------------
Name | YURIANNA REYES
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 708-673-5548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------