MEDICARE: ELEVATED LIFE THERAPY, 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1770217614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATED LIFE THERAPY, PLLC

Provider Business Mailing Address
First Line	:	401 E JEFFERSON ST
Second Line	:
City	:	GARDNER
State	:	IL
Zip	:	60424-7011
Country	:	US
Telephone Number	:	815-250-7525
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 E MAIN ST STE 307
Second Line	:
City	:	MORRIS
State	:	IL
Zip	:	60450-2149
Country	:	US
Telephone Number	:	815-661-6257
Fax Number	:

Authorized Official
Title or Position	:	LCPC
Name	:	RAEANN LOWRY
Credential	:
Telephone Number	:	815-250-7525

Provider Enumeration Date	:	07/15/2022
Last Update Date	:	07/15/2022

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Directions to “ELEVATED LIFE THERAPY, PLLC ” Practice Location

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