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General NPI Number Information
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NPI Number | 1841920915
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Entity Type | Organization
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Legal Business Name | CONSTELLATION COLLECTIVE
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Dates
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Enumeration Date | 06/13/2022
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Last Update Date | 06/13/2022
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Provider Practice Location Address
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Address Line | 6666 N WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60645-5106
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Country | US
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Telephone | 312-857-6716
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 W ELMDALE AVE UNIT 3
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City | CHICAGO
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State | IL
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Zip | 60660-2588
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | STAFF THERAPIST
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Name | JESSICA LEVINE
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Credential | LCSW
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Telephone | 224-215-6524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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