MEDICARE: ROSARIUM PSYCHOTHERAPY, 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1841990983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSARIUM PSYCHOTHERAPY, LLC

Provider Business Mailing Address
First Line	:	3742 N MAGNOLIA AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3846
Country	:	US
Telephone Number	:	773-484-0329
Fax Number	:

Provider Business Practice Location Address
First Line	:	3742 N MAGNOLIA AVE APT 3
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3846
Country	:	US
Telephone Number	:	773-484-0329
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER AND PSYCHOTHERAPIST
Name	:	KYLE EUGENE SHIVER
Credential	:	LCPC
Telephone Number	:	773-484-0329

Provider Enumeration Date	:	03/07/2023
Last Update Date	:	03/07/2023

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