=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184289118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBRACE CORAZON COUNSELING PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2019
-----------------------------------------------------
Last Update Date | 01/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 917 W 18TH ST STE 216
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-581-8018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4045 W 58TH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60629-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-988-1162
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/THERAPIST
-----------------------------------------------------
Name | MS. SUSIE MOYA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 708-581-8018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------