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General NPI Number Information
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NPI Number | 1366850992
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Entity Type | Organization
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Legal Business Name | MIND BALANCE, INC
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 115 N MARION ST SUITE 1
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City | OAK PARK
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State | IL
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Zip | 60301-1503
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Country | US
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Telephone | 708-834-0909
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Fax |
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Provider Business Mailing Address
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Address Line | 115 N MARION ST SUITE 1
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City | OAK PARK
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State | IL
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Zip | 60301-1503
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Country | US
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Telephone | 708-834-0909
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ROSE LAWRENCE
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Credential |
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Telephone | 708-834-0909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180009210
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License Number State | IL
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