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General NPI Number Information
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NPI Number | 1417629353
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Entity Type | Organization
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Legal Business Name | BLUE WILLOW THERAPY, LLC
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Dates
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Enumeration Date | 09/29/2021
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Last Update Date | 12/20/2021
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Provider Practice Location Address
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Address Line | 2343 W WINONA ST
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City | CHICAGO
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State | IL
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Zip | 60625-1853
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Country | US
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Telephone | 217-691-2760
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Fax |
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Provider Business Mailing Address
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Address Line | 2343 W WINONA ST APT 2E
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City | CHICAGO
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State | IL
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Zip | 60625-1853
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Country | US
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Telephone | 217-691-2760
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Fax |
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Authorized Official
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Title or Position | CLINICAL THERAPIST
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Name | MRS. TANEKA TAYLOR
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Credential | LCSW
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Telephone | 217-691-2760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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