MEDICARE: GENERATIVE CHAOS

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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1346973278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENERATIVE CHAOS

Provider Business Mailing Address
First Line	:	1518 N CLEVELAND AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1518 N CLEVELAND AVE # 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-1110
Country	:	US
Telephone Number	:	773-570-0498
Fax Number	:

Authorized Official
Title or Position	:	OWNER AND OPERATOR
Name	:	THEODORA CUNNINGHAM
Credential	:	LCPC
Telephone Number	:	773-570-0498

Provider Enumeration Date	:	07/07/2022
Last Update Date	:	07/07/2022

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