MEDICARE: WATERBROOK THERAPY, INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528525383
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERBROOK THERAPY, INC.

Provider Business Mailing Address
First Line	:	10540 S WESTERN AVE STE 406
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2529
Country	:	US
Telephone Number	:	773-559-5958
Fax Number	:	773-442-0085

Provider Business Practice Location Address
First Line	:	10540 S WESTERN AVE STE 406
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-2529
Country	:	US
Telephone Number	:	773-559-5958
Fax Number	:	773-442-0085

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT PRESTON STANFORD
Credential	:	LCPC
Telephone Number	:	312-725-0646

Provider Enumeration Date	:	02/27/2019
Last Update Date	:	02/27/2019

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