MEDICARE: INNER BALANCE PSYCHOTHERAPY SERVICES LTD

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1154510279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER BALANCE PSYCHOTHERAPY SERVICES LTD

Provider Business Mailing Address
First Line	:	561 W DIVERSEY PKWY
Second Line	:	SUITE 210
City	:	CHICAGO
State	:	IL
Zip	:	60614-6068
Country	:	US
Telephone Number	:	773-244-9620
Fax Number	:	773-244-9622

Provider Business Practice Location Address
First Line	:	561 W DIVERSEY PKWY
Second Line	:	SUITE 210
City	:	CHICAGO
State	:	IL
Zip	:	60614-6068
Country	:	US
Telephone Number	:	773-244-9620
Fax Number	:	773-244-9622

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNIFER WANG
Credential	:	L.C.S.W.
Telephone Number	:	773-244-9620

Provider Enumeration Date	:	10/15/2007
Last Update Date	:	01/12/2014

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