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General NPI Number Information
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NPI Number | 1770065088
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Entity Type | Organization
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Legal Business Name | NOURISH PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 09/04/2018
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Last Update Date | 09/04/2018
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Provider Practice Location Address
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Address Line | 5225 OLD ORCHARD RD STE 29
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City | SKOKIE
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State | IL
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Zip | 60077-1027
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Country | US
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Telephone | 773-403-2374
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Fax |
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Provider Business Mailing Address
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Address Line | 5225 OLD ORCHARD RD STE 29
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City | SKOKIE
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State | IL
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Zip | 60077-1027
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Country | US
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Telephone | 773-403-2374
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Fax |
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | LINNET MENDEZ
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Credential | LCPC
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Telephone | 773-403-2374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149.018995
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License Number State | IL
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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 | 149.013079
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180.007420
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License Number State | IL
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