MEDICARE: SOMAWISE CHICAGO

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1821657289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOMAWISE CHICAGO

Provider Business Mailing Address
First Line	:	2761 W SAINT MARY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4022
Country	:	US
Telephone Number	:	312-810-9553
Fax Number	:

Provider Business Practice Location Address
First Line	:	2761 W SAINT MARY ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4022
Country	:	US
Telephone Number	:	312-810-9553
Fax Number	:

Authorized Official
Title or Position	:	LICENSED COUNSELOR
Name	:	RACHEL SHERRON
Credential	:	LCPC
Telephone Number	:	312-810-9553

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	06/10/2019

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Directions to “SOMAWISE CHICAGO ” Practice Location

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