=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558745406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL CONNECTIONS BEHAVIORAL HEALTH PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2015
-----------------------------------------------------
Last Update Date | 07/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 S YORK ST STE 201
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-351-8831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1413 VICTORIA AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60163-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-351-8831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ROSEMARY SPIZZIRRI
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 708-351-8831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150015385
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149009677
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------