=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245830298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A BEAUTIFUL MIND, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2020
-----------------------------------------------------
Last Update Date | 02/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9046 S JUSTINE ST APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60620-5033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-304-6999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5113 S HARPER AVE STE 2C
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60615-4119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/FOUNDER
-----------------------------------------------------
Name | CHIQUITA LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-304-3699
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------