=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750995650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUMBOLDT PARK COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2020
-----------------------------------------------------
Last Update Date | 10/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 938 N CALIFORNIA AVE COMMERCIAL UNIT
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-1435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-620-0408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3446 W HIRSCH ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60651-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-620-0408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PSYCHOTHERAPIST
-----------------------------------------------------
Name | CAROLYN SELLERS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 312-620-0408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------