=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215314414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTSOURCE THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2015
-----------------------------------------------------
Last Update Date | 04/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 E COLORADO AVE
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-1385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-837-3319
-----------------------------------------------------
Fax | 815-469-6481
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 523
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-0523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-837-3319
-----------------------------------------------------
Fax | 815-469-6481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. GALE NIENHUIS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 708-837-3319
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149014484
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------