MEDICARE: BALANCED AWAKENING, 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	103TC0700X	Clinical Psychologist	071008952	IL

General Provider Information

NPI Number	:	1285024463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCED AWAKENING, PC

Provider Business Mailing Address
First Line	:	4043 N RAVENSWOOD AVE STE 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5683
Country	:	US
Telephone Number	:	507-407-4363
Fax Number	:

Provider Business Practice Location Address
First Line	:	4043 N RAVENSWOOD AVE STE 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-5683
Country	:	US
Telephone Number	:	312-967-4669
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL PSYCHOLOGIST
Name	:	HANNAH YANG
Credential	:	PSY.D.
Telephone Number	:	507-407-4363

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	02/05/2020

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