MEDICARE: WILD IRIS PSYCHOTHERAPY

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1801685425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD IRIS PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	4578 N MEADE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3005
Country	:	US
Telephone Number	:	773-964-5225
Fax Number	:

Provider Business Practice Location Address
First Line	:	4578 N MEADE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-3005
Country	:	US
Telephone Number	:	773-964-5225
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MS. RACHELLE LEAH DEBEHNKE
Credential	:	LCPC, CADC
Telephone Number	:	773-964-5225

Provider Enumeration Date	:	05/01/2025
Last Update Date	:	05/01/2025

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