=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891226767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH SHORE RESILIENT FAMILY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2017
-----------------------------------------------------
Last Update Date | 09/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 636 CHURCH ST STE 416
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-4580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-461-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2636 PRAIRIE AVE APT A
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-5743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-461-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ CLINICIAN
-----------------------------------------------------
Name | MARY ALEXANDRA 'ALEX DOTY
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 847-461-9731
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149-009018
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------