MEDICARE: HUNGRY SOULS 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1851861603
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUNGRY SOULS THERAPY, LLC.

Provider Business Mailing Address
First Line	:	2650 W MONTROSE AVE STE 307
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1561
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 W MONTROSE AVE STE 307
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1561
Country	:	US
Telephone Number	:	312-479-0347
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MIKKI GUERRA
Credential	:	LCSW, CADC
Telephone Number	:	312-479-0347

Provider Enumeration Date	:	12/04/2018
Last Update Date	:	12/04/2018

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