=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265147870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EN ROUTE COUNSELING AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4401 N CLARK ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-922-0304
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 W MONTROSE AVE # 2028
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60641-2140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIAMOND TUCKER
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 773-922-0304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------