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General NPI Number Information
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NPI Number | 1396434734
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Entity Type | Organization
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Legal Business Name | WILDLIGHT THERAPY
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Dates
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Enumeration Date | 05/02/2023
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Last Update Date | 05/02/2023
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Provider Practice Location Address
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Address Line | 5547 N RAVENSWOOD AVE STE 407
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City | CHICAGO
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State | IL
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Zip | 60640-1125
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Country | US
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Telephone | 908-358-5802
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Fax |
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Provider Business Mailing Address
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Address Line | 4240 N CLARENDON AVE APT 403N
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City | CHICAGO
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State | IL
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Zip | 60613-1537
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. ADRIANA BRODYN
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Credential | PHD
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Telephone | 908-358-5802
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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 |
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License Number State |
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