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General NPI Number Information
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NPI Number | 1225230378
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Entity Type | Organization
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Legal Business Name | THE ASPEN CENTER FOR COUNSELING AND CONSULTATION LLC
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Dates
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Enumeration Date | 06/01/2007
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Last Update Date | 04/01/2011
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Provider Practice Location Address
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Address Line | 30 N MICHIGAN AVE SUITE 925
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City | CHICAGO
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State | IL
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Zip | 60601-3463
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Country | US
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Telephone | 312-540-8977
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Fax |
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Provider Business Mailing Address
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Address Line | 30 N MICHIGAN AVE SUITE 925
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City | CHICAGO
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State | IL
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Zip | 60602-3402
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Country | US
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Telephone | 312-540-8977
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. ALISA MATTESON MUNDT
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Credential | PSYD
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Telephone | 312-540-8977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.007178
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License Number State | IL
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