=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700398922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OMNIS COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2017
-----------------------------------------------------
Last Update Date | 10/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 863 CENTER CT UNIT A
-----------------------------------------------------
City | SHOREWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60404-8512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-901-1154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1070 N STONE CT
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-3318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-901-1154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. RIMA MICKUS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 630-901-1154
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180008021
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------