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General NPI Number Information
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NPI Number | 1699478990
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Entity Type | Organization
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Legal Business Name | MY ART THERAPY STUDIO, PLLC
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Dates
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Enumeration Date | 03/24/2023
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 3124 W LOGAN BLVD
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City | CHICAGO
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State | IL
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Zip | 60647-1627
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Country | US
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Telephone | 312-278-7628
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Fax |
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Provider Business Mailing Address
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Address Line | 4610 N CLARK ST # 1203
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City | CHICAGO
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State | IL
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Zip | 60640-4620
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Country | US
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Telephone | 312-278-7628
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Fax |
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Authorized Official
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Title or Position | OWNER, PROFESSIONAL COUNSELOR
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Name | MEREDITH RAQUE
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Credential | LCPC, ATR-BC
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Telephone | 502-554-4666
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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