MEDICARE: LG THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker
3	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1306498217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LG THERAPY, LLC

Provider Business Mailing Address
First Line	:	1039 MAPLETON AVE
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-1405
Country	:	US
Telephone Number	:	773-968-8694
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 E WASHINGTON ST STE 1613
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60602-1819
Country	:	US
Telephone Number	:	773-968-8694
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND THERAPIST
Name	:	LAURA SHAMORIAN GOSSIN
Credential	:	LMFT
Telephone Number	:	773-968-8694

Provider Enumeration Date	:	07/10/2019
Last Update Date	:	07/10/2019

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Directions to “LG THERAPY, LLC ” Practice Location

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