MEDICARE: CONSCIOUS RESET THERAPY AND WELLNESS, PLLC

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	:	1609745470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSCIOUS RESET THERAPY AND WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	4334 N CLARENDON AVE APT 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1563
Country	:	US
Telephone Number	:	703-405-5631
Fax Number	:

Provider Business Practice Location Address
First Line	:	4334 N CLARENDON AVE APT 302
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-1563
Country	:	US
Telephone Number	:	703-405-5631
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. VINCENT HENNEBURG
Credential	:	LCSW
Telephone Number	:	703-405-5631

Provider Enumeration Date	:	10/31/2025
Last Update Date	:	10/31/2025

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