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General NPI Number Information
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NPI Number | 1720341993
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Entity Type | Organization
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Legal Business Name | NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING
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Dates
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Enumeration Date | 06/21/2012
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Last Update Date | 06/21/2012
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Provider Practice Location Address
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Address Line | 1770 W BERTEAU AVE SUITE 302A
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City | CHICAGO
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State | IL
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Zip | 60613-1849
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Country | US
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Telephone | 773-791-0469
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Fax |
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Provider Business Mailing Address
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Address Line | 1770 W BERTEAU AVE SUITE 302A
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City | CHICAGO
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State | IL
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Zip | 60613-1849
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Country | US
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Telephone | 773-791-0469
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. JOSH SMITH HETHERINGTON
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Credential | LMFT, LCPC
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Telephone | 773-791-0469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 180.003937
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 166.000557
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License Number State | IL
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