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General NPI Number Information
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NPI Number | 1811605470
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Entity Type | Organization
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Legal Business Name | MINDFUL THERAPY & WELLNESS, PLLC
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Dates
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Enumeration Date | 11/11/2022
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Last Update Date | 05/31/2024
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Provider Practice Location Address
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Address Line | 655 W IRVING PARK RD APT 4817
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City | CHICAGO
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State | IL
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Zip | 60613-3138
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Country | US
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Telephone | 773-203-5374
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Fax |
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Provider Business Mailing Address
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Address Line | 5332 W WINDSOR AVE UNIT 2B C/O DIANE TARCHALA
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City | CHICAGO
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State | IL
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Zip | 60630-3138
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Country | US
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Telephone | 773-203-5374
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Fax |
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Authorized Official
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Title or Position | OWNER/PSYCHOTHERAPIST
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Name | DEVIN WILLIAM BERCAW
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Credential | LCPC
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Telephone | 773-203-5374
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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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