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General NPI Number Information
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NPI Number | 1699582890
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Entity Type | Organization
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Legal Business Name | PRAY GROUNDS
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Dates
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Enumeration Date | 12/12/2024
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 10157 S WALLACE ST
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City | CHICAGO
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State | IL
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Zip | 60628-1841
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Country | US
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Telephone | 708-705-2642
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Fax |
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Provider Business Mailing Address
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Address Line | 1519 W WARREN BLVD
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City | CHICAGO
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State | IL
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Zip | 60607-1819
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Country | US
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Telephone | 773-669-6073
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Fax |
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Authorized Official
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Title or Position | LICENSED CLINICAL THERAPIST
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Name | RENECHA DORSEY
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Credential | LCSW
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Telephone | 708-705-2642
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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