=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215258991
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND & BODY BALANCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2010
-----------------------------------------------------
Last Update Date | 11/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 W BELMONT AVE STE 407
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-3242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-403-5149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4443 N RICHMOND ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-3823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-403-5149
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | JOANNE FLOM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-403-5149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149010662
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------