=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790525731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDEFINE PSYCHOTHERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 W IRVING PARK RD STE 205B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-666-1287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 W IRVING PARK RD STE 205B
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-2599
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-666-1287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELLE MALTERS
-----------------------------------------------------
Credential | LCP
-----------------------------------------------------
Telephone | 872-666-1287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------