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General NPI Number Information
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NPI Number | 1568091098
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Entity Type | Organization
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Legal Business Name | INTENTIONAL LIVING LLC
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Dates
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Enumeration Date | 04/06/2020
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Last Update Date | 04/06/2020
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Provider Practice Location Address
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Address Line | 1041 N WESTERN AVE FL 1
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City | CHICAGO
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State | IL
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Zip | 60622-3571
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Country | US
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Telephone | 312-566-8417
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Fax |
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Provider Business Mailing Address
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Address Line | 1841 N MONTICELLO AVE APT 1E
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City | CHICAGO
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State | IL
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Zip | 60647-4741
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Country | US
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Telephone | 630-392-8628
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHELLE DUDA
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Credential |
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Telephone | 312-566-8417
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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