=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659755700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETH HENNESSEY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2015
-----------------------------------------------------
Last Update Date | 07/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3523 N LINCOLN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-929-6261
-----------------------------------------------------
Fax | 773-929-6762
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1243 W GRANVILLE AVE # 2W
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-304-7148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | ELIZABETH HENNESSEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-304-7148
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 108.007468
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------