=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669183166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND AND MOVEMENT THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3231 S. HALSTED ST #157
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-725-0540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3231 S. HALSTED ST #157
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-725-0540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PROFESSIONAL COUN
-----------------------------------------------------
Name | LAURA RAE VENDITTI
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 312-725-0540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------