=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255158879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING TEA THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2024
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3727 N HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-305-1304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3727 N HALSTED ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-305-1304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NADA PAVLOVIC
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 312-305-1304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------