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General NPI Number Information
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NPI Number | 1982195301
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Entity Type | Organization
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Legal Business Name | GREEN DOOR THERAPY LLC
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Dates
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Enumeration Date | 05/21/2018
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Last Update Date | 11/09/2021
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Provider Practice Location Address
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Address Line | 126 N YORK ST STE 2
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City | ELMHURST
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State | IL
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Zip | 60126-2888
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Country | US
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Telephone | 163-038-4956
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7109
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City | VILLA PARK
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State | IL
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Zip | 60181-7109
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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 | CLINICAL THERAPIST/ SUPERVISOR
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Name | BROOKE MADERA
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Credential | MS, LCPC, CADC
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Telephone | 630-384-9560
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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