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General NPI Number Information
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NPI Number | 1144686122
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Entity Type | Organization
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Legal Business Name | FREESTONE PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 01/06/2016
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 4619 N RAVENSWOOD AVE SUITE 303C
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City | CHICAGO
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State | IL
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Zip | 60640-4580
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Country | US
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Telephone | 312-834-7778
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Fax |
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Provider Business Mailing Address
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Address Line | 4619 N RAVENSWOOD AVE SUITE 303C
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City | CHICAGO
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State | IL
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Zip | 60640-4580
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Country | US
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Telephone | 312-834-7778
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | KEVIN BARRETT
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Credential | LCSW
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Telephone | 312-834-7778
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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 | 149015772
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License Number State | IL
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