MEDICARE: NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING

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	101YM0800X	Mental Health Counselor	180.003937	IL
2	106H00000X	Marriage & Family Therapist	166.000557	IL

General Provider Information

NPI Number	:	1720341993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING

Provider Business Mailing Address
First Line	:	1770 W BERTEAU AVE
Second Line	:	SUITE 302A
City	:	CHICAGO
State	:	IL
Zip	:	60613-1849
Country	:	US
Telephone Number	:	773-791-0469
Fax Number	:

Provider Business Practice Location Address
First Line	:	1770 W BERTEAU AVE
Second Line	:	SUITE 302A
City	:	CHICAGO
State	:	IL
Zip	:	60613-1849
Country	:	US
Telephone Number	:	773-791-0469
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. JOSH SMITH HETHERINGTON
Credential	:	LMFT, LCPC
Telephone Number	:	773-791-0469

Provider Enumeration Date	:	06/21/2012
Last Update Date	:	06/21/2012

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