=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861203309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANDSTONE THERAPY CHICAGO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2015 W DICKENS AVE APT G
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-728-8644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2015 W DICKENS AVE APT G
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-4530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-728-8644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | BRIDGET CLARE DONNELLY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 219-728-8644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------