=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740726330
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A CLEARER MIND LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2017
-----------------------------------------------------
Last Update Date | 01/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E SCHILLER ST STE 252
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-945-5074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 E SCHILLER ST STE 252
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60126-2858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-945-5074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | KRISTINE HUDZIK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 858-945-5074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 149.015920
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------