=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821451477
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMELIORATED WEALTH OF WISDOM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2016
-----------------------------------------------------
Last Update Date | 03/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1158 W TAYLOR ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-4213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-301-5061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1158 W TAYLOR ST
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60607-4213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-301-5061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRMAN CEO
-----------------------------------------------------
Name | YASMEEN STRUDIVANT
-----------------------------------------------------
Credential | ELDER
-----------------------------------------------------
Telephone | 773-301-5061
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------