=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578800744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LIGHT OF THE HEART: A COMMUNITY ART THERAPY PROJECT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2013
-----------------------------------------------------
Last Update Date | 01/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2240 BANNISTER LN
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 640-486-4078
-----------------------------------------------------
Fax | 630-281-5374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2240 BANNISTER LN
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 640-486-4078
-----------------------------------------------------
Fax | 630-281-5374
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MELISSA JANE HEDLUND
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 630-486-4078
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 180.008048
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------