MEDICARE: MINDFUL CONNECTIONS BEHAVIORAL HEALTH PC

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	104100000X	Social Worker	150015385	IL
2	1041C0700X	Clinical Social Worker	149009677	IL

General Provider Information

NPI Number	:	1558745406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL CONNECTIONS BEHAVIORAL HEALTH PC

Provider Business Mailing Address
First Line	:	1413 VICTORIA AVE
Second Line	:
City	:	BERKELEY
State	:	IL
Zip	:	60163-1464
Country	:	US
Telephone Number	:	708-351-8831
Fax Number	:

Provider Business Practice Location Address
First Line	:	116 S YORK ST STE 201
Second Line	:
City	:	ELMHURST
State	:	IL
Zip	:	60126-3432
Country	:	US
Telephone Number	:	708-351-8831
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ROSEMARY SPIZZIRRI
Credential	:	LCSW
Telephone Number	:	708-351-8831

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	07/09/2015

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