=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629729108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR LIBERATION & WELLNESS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2022
-----------------------------------------------------
Last Update Date | 01/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 661 W LAKE ST STE 2S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-219-4520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 661 W LAKE ST STE 2S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60661-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-219-4520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOLOGIST
-----------------------------------------------------
Name | DR. LINCOLN HILL
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 312-219-4520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------