MEDICARE: EMBODY & MIND COLLECTIVE

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

General Provider Information

NPI Number	:	1750004370
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMBODY & MIND COLLECTIVE

Provider Business Mailing Address
First Line	:	53 W JACKSON BLVD STE 1334
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3548
Country	:	US
Telephone Number	:	773-309-1542
Fax Number	:

Provider Business Practice Location Address
First Line	:	53 W JACKSON BLVD STE 1334
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60604-3548
Country	:	US
Telephone Number	:	773-309-1542
Fax Number	:

Authorized Official
Title or Position	:	OWNER & FOUNDER
Name	:	TESA EMMART
Credential	:	LCPC, LMHC
Telephone Number	:	773-309-1542

Provider Enumeration Date	:	09/20/2022
Last Update Date	:	09/20/2022

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