=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508663675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BIRDIE BENNETT LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2025
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5537 N CLARK ST APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-0751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-570-1220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1348 W CHASE AVE APT 3
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-6366
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-734-3057
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 178.020714
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------