=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801425335
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHER GROUND WELLNESS GROUP LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2020
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1053 LAKE ST STE 3
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-317-2056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1053 LAKE ST STE 3
-----------------------------------------------------
City | OAK PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60301-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-317-2056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FELICIA M OWENS
-----------------------------------------------------
Credential | PSY.D
-----------------------------------------------------
Telephone | 773-317-2056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------