=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598469959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REFLECTIVE MIND PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2023
-----------------------------------------------------
Last Update Date | 08/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1604 CHICAGO AVE STE 8
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-6017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-298-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6446 N SHERIDAN RD # 511
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60626-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BRIAN MACWILLIAMS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 312-298-9355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------