=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699422501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ITB THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2022
-----------------------------------------------------
Last Update Date | 04/28/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 MOONEY DR
-----------------------------------------------------
City | BOURBONNAIS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60914-2171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-529-0825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31526 S WILL CENTER RD
-----------------------------------------------------
City | PEOTONE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60468-9142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 779-529-0825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | LAURA L MILLS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 779-529-0825
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------