MEDICARE: ELEVATION INDIVIDUAL AND FAMILY THERAPY, LLC

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
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1760091235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATION INDIVIDUAL AND FAMILY THERAPY, LLC

Provider Business Mailing Address
First Line	:	19150 KEDZIE AVE STE 201
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-4541
Country	:	US
Telephone Number	:	708-513-8170
Fax Number	:

Provider Business Practice Location Address
First Line	:	19150 KEDZIE AVE STE 201
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-4541
Country	:	US
Telephone Number	:	708-513-8170
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIONNA HARRIS
Credential	:	LCSW
Telephone Number	:	708-513-8170

Provider Enumeration Date	:	07/30/2020
Last Update Date	:	04/19/2023

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