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General NPI Number Information
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NPI Number | 1902146202
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Entity Type | Organization
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Legal Business Name | HEART SOURCE THERAPY
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Dates
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Enumeration Date | 02/22/2013
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Last Update Date | 02/22/2013
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Provider Practice Location Address
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Address Line | 33 E COLORADO AVE
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City | FRANKFORT
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State | IL
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Zip | 60423-1385
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Country | US
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Telephone | 708-837-3319
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Fax | 630-262-3383
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Provider Business Mailing Address
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Address Line | 33 E COLORADO AVE
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City | FRANKFORT
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State | IL
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Zip | 60423-1385
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Country | US
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Telephone | 708-837-3319
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GALE NIENHUIS
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Credential | LCPC
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Telephone | 708-837-3319
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 149014484
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License Number State | IL
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