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General NPI Number Information
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NPI Number | 1295124980
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Entity Type | Organization
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Legal Business Name | THERAPEUTIC HEALING LLC
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Dates
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Enumeration Date | 01/18/2015
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Last Update Date | 01/18/2015
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Provider Practice Location Address
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Address Line | 625 W MADISON ST APT 4304
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City | CHICAGO
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State | IL
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Zip | 60661-2753
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Country | US
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Telephone | 312-283-4475
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Fax |
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Provider Business Mailing Address
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Address Line | 625 W MADISON ST APT 4304
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City | CHICAGO
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State | IL
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Zip | 60661-2753
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Country | US
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Telephone | 517-483-3424
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. MARIAM R MOURAD
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Credential | PH.D.
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Telephone | 312-283-4475
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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 | 071.008016
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License Number State | IL
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