MEDICARE: PARKSIDE THERAPY

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	:	1356817522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARKSIDE THERAPY

Provider Business Mailing Address
First Line	:	4230 N PARKSIDE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-1825
Country	:	US
Telephone Number	:	630-291-7825
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 N LINCOLN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1807
Country	:	US
Telephone Number	:	630-291-7825
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/THERAPIST
Name	:	REGINA KING
Credential	:
Telephone Number	:	630-291-7825

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	10/16/2018

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Directions to “PARKSIDE THERAPY ” Practice Location

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