MEDICARE: INKWELL PSYCHOTHERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YP2500X	Professional Counselor
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1942832977
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INKWELL PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	4305 N LINCOLN AVE STE L
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1807
Country	:	US
Telephone Number	:	773-669-4975
Fax Number	:

Provider Business Practice Location Address
First Line	:	4305 N LINCOLN AVE STE L
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-1807
Country	:	US
Telephone Number	:	773-669-4975
Fax Number	:	844-669-3667

Authorized Official
Title or Position	:	OWNER, THERAPIST
Name	:	STEPHANIE M FOWLER
Credential	:	LCPC, CADC
Telephone Number	:	773-669-4975

Provider Enumeration Date	:	02/07/2020
Last Update Date	:	02/07/2020

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Directions to “INKWELL PSYCHOTHERAPY ” Practice Location

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