MEDICARE: SALT & SAND PSYCHOTHERAPY 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1174380786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT & SAND PSYCHOTHERAPY PLLC

Provider Business Mailing Address
First Line	:	2415 W SHERWIN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-1427
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 W WASHINGTON ST STE 1506
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-3220
Country	:	US
Telephone Number	:	872-222-9345
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	TARA ARIANNE TILLMAN
Credential	:	LCSW
Telephone Number	:	872-222-9345

Provider Enumeration Date	:	02/29/2024
Last Update Date	:	03/24/2024

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