MEDICARE: DOVETAIL PSYCHOTHERAPY AND WELLNESS 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1073482600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOVETAIL PSYCHOTHERAPY AND WELLNESS PLLC

Provider Business Mailing Address
First Line	:	680 N LAKE SHORE DR STE 110-1759
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4546
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 N LAKE SHORE DR STE 110-1759
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-4546
Country	:	US
Telephone Number	:	708-263-5200
Fax Number	:

Authorized Official
Title or Position	:	OWNER / LCPC
Name	:	ELIZABETH OSULLIVAN
Credential	:	M.ED
Telephone Number	:	708-263-5200

Provider Enumeration Date	:	11/03/2025
Last Update Date	:	11/03/2025

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