MEDICARE: URBANSTREETZ THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1023651049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	URBANSTREETZ THERAPY LLC

Provider Business Mailing Address
First Line	:	8364 S KENWOOD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6437
Country	:	US
Telephone Number	:	773-703-8486
Fax Number	:

Provider Business Practice Location Address
First Line	:	9204 S COMMERCIAL AVE STE 206
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-2197
Country	:	US
Telephone Number	:	773-703-8486
Fax Number	:	773-530-7588

Authorized Official
Title or Position	:	LCSW/OWNER
Name	:	MRS. JESSICA M BURNETTE
Credential	:	LCSW
Telephone Number	:	773-703-8486

Provider Enumeration Date	:	10/22/2019
Last Update Date	:	09/17/2022

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