=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508213091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO CENTER FOR CONSCIOUS LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2016
-----------------------------------------------------
Last Update Date | 05/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 N RAVENSWOOD AVE SUITE 211
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-480-5297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 N RAVENSWOOD AVE SUITE 211
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-480-5297
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MEREDITH COHN SRIVASTAVA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 773-480-5297
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149011049
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------