=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366831588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHYLLIS BARNES BOOTH MA, LMFT, LCPC.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2015
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5550 SO. SOUTH SHORE DRIVE #1415
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-753-4674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5550 SOUTH SOUTH SHORE DRIVE #1415
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-753-4674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180-000-574
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 166-000-152
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------