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General NPI Number Information
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NPI Number | 1407361314
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Entity Type | Organization
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Legal Business Name | PRACTICAL AUDACITY LLC
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Dates
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Enumeration Date | 12/14/2017
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Last Update Date | 12/14/2017
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Provider Practice Location Address
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Address Line | 3530 W PALMER ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60647-3575
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Country | US
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Telephone | 318-547-1823
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Fax |
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Provider Business Mailing Address
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Address Line | 3530 W PALMER ST APT 2
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City | CHICAGO
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State | IL
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Zip | 60647-3575
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Country | US
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Telephone | 318-547-1823
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Fax |
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Authorized Official
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Title or Position | FOUNDER AND THERAPIST
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Name | RENA MCDANIEL
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Credential | MED, LCPC
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Telephone | 318-547-1823
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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 | 180.010161
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License Number State | IL
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