MEDICARE: VOWS OF LIGHT, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	104100000X	Social Worker
4	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1487380440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VOWS OF LIGHT, LLC

Provider Business Mailing Address
First Line	:	2024 S WABASH AVE APT 306
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2283
Country	:	US
Telephone Number	:	803-638-8373
Fax Number	:

Provider Business Practice Location Address
First Line	:	2024 S WABASH AVE APT 306
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2283
Country	:	US
Telephone Number	:	803-638-8373
Fax Number	:

Authorized Official
Title or Position	:	LEAD THERAPIST/OWNER
Name	:	ICELYLNN BALDWIN
Credential	:	LISW-CP, LCSW
Telephone Number	:	803-730-1023

Provider Enumeration Date	:	07/30/2022
Last Update Date	:	07/30/2022

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Directions to “VOWS OF LIGHT, LLC ” Practice Location

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