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General NPI Number Information
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NPI Number | 1225779374
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Entity Type | Organization
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Legal Business Name | INNER TIDES COUNSELING, PLLC
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Dates
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Enumeration Date | 04/05/2022
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Last Update Date | 05/03/2022
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Provider Practice Location Address
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Address Line | 3216 N DRAKE AVE
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City | CHICAGO
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State | IL
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Zip | 60618-5411
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Country | US
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Telephone | 815-280-8434
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Fax |
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Provider Business Mailing Address
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Address Line | 3216 N DRAKE AVE
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City | CHICAGO
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State | IL
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Zip | 60618-5411
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Country | US
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Telephone | 815-280-8434
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | DARLENE BUNCH
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Credential | LCSW
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Telephone | 872-256-2294
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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