MEDICARE: WELL GROUNDED THERAPY PLLC

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	:	1053035444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELL GROUNDED THERAPY PLLC

Provider Business Mailing Address
First Line	:	6351 W MONTROSE AVE # 203
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1563
Country	:	US
Telephone Number	:	630-532-7188
Fax Number	:

Provider Business Practice Location Address
First Line	:	3429 N OAK PARK AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-3720
Country	:	US
Telephone Number	:	630-532-7188
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	DOMINIQUE RODRIGUEZ
Credential	:	LCPC
Telephone Number	:	630-532-7188

Provider Enumeration Date	:	09/28/2022
Last Update Date	:	10/28/2024

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