MEDICARE: KATJA AISHA MIMMS LCPC

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	101YP2500X	Professional Counselor	180.011266	IL

General Provider Information

NPI Number	:	1407689631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATJA AISHA MIMMS LCPC

Provider Business Mailing Address
First Line	:	420 E 45TH PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60653-4110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 E RANDOLPH ST FL 4
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60601-5099
Country	:	US
Telephone Number	:	312-653-7645
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	08/22/2024

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