=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730833369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRESHOLDS HEALTH, NFP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2022
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 334 N MENARD AVE FL 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60644-2157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-572-5210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 S LA SALLE ST STE 1410
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60603-3579
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE ASSISTANT
-----------------------------------------------------
Name | MARCELLA KLAUER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-572-5480
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------