MEDICARE: BABA YAGA THERAPY PLLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1982332243
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BABA YAGA THERAPY PLLC

Provider Business Mailing Address
First Line	:	3452 N AVERS AVE APT 3R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5214
Country	:	US
Telephone Number	:	773-234-2898
Fax Number	:

Provider Business Practice Location Address
First Line	:	3452 N AVERS AVE APT 3R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-5214
Country	:	US
Telephone Number	:	773-234-2898
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	KYRA L KEUBEN
Credential	:	LCSW
Telephone Number	:	773-234-2898

Provider Enumeration Date	:	08/12/2022
Last Update Date	:	12/10/2023

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