MEDICARE: YOUR AUTISTIC THERAPIST PC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1033949490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR AUTISTIC THERAPIST PC

Provider Business Mailing Address
First Line	:	1055 W BRYN MAWR AVE STE F
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4692
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5655 N WAYNE AVE APT 1S
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-5543
Country	:	US
Telephone Number	:	773-242-9427
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUE COOK
Credential	:	LCSW
Telephone Number	:	773-242-9427

Provider Enumeration Date	:	08/01/2024
Last Update Date	:	08/01/2024

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Directions to “YOUR AUTISTIC THERAPIST PC ” Practice Location

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