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General NPI Number Information
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NPI Number | 1760137558
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Entity Type | Organization
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Legal Business Name | THE VIDERI CLINIC FOR EMOTIONAL HEALTH PLLC
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Dates
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Enumeration Date | 02/20/2022
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Last Update Date | 02/20/2022
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Provider Practice Location Address
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Address Line | 207 E OHIO ST # 386
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City | CHICAGO
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State | IL
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Zip | 60611-4092
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Country | US
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Telephone | 708-351-8212
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Fax |
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Provider Business Mailing Address
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Address Line | 207 E OHIO ST # 386
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City | CHICAGO
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State | IL
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Zip | 60611-4092
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FOUNDER AND DIRECTOR
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Name | FERNANDO GONZALEZ III
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Credential |
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Telephone | 708-351-8212
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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