=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659850436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALCHEMY PERFORMANCE CONSULTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2018
-----------------------------------------------------
Last Update Date | 08/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4737 N CLARK ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-7758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-542-3408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5204 N LEAVITT ST APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-215-5052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. MICHELLE L MONTERO
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 773-542-3408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 071.009074
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071.009074
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------