=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649833575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT COUNSELING GROUP PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 04/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3047 N LINCOLN AVE UNIT 400
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-4274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-947-3879
-----------------------------------------------------
Fax | 773-404-5837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3047 N LINCOLN AVE UNIT 400
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-4274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-947-3879
-----------------------------------------------------
Fax | 773-404-5837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JANE ELIZABETH SHERSHER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 609-947-3879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------