=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790314284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEMENT THERAPY GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2020
-----------------------------------------------------
Last Update Date | 02/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3143 N SAWYER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-320-3245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3143 N SAWYER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60618-6802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-320-3245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/AGENT
-----------------------------------------------------
Name | ANDREA CELERIO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-320-3245
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------