=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164915542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAWN LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2018
-----------------------------------------------------
Last Update Date | 06/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N MICHIGAN AVE STE 726
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-951-1177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10015 S KING DR
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60628-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-680-0442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ALLYSE STURDIVANT WILLIAMS
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 773-680-0442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 071008324
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------