| Embodied Change, Inc | |
|
4055 W Peterson Ave Ste 104 Chicago IL 60646-6183 | |
| (773) 726-7290 | |
| Not Available |
| Full Name | Embodied Change, Inc |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 4055 W Peterson Ave Ste 104, Chicago, Illinois |
| Authorized Official Name and Position | Mollie Ryan Stock (OWNER) |
| Authorized Official Contact | 7737267290 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Embodied Change, Inc 5255 W Ardmore Ave Chicago IL 60646-6520 Ph: () - | Embodied Change, Inc 4055 W Peterson Ave Ste 104 Chicago IL 60646-6183 Ph: (773) 726-7290 |
| NPI Number | 1730656000 |
|---|---|
| Provider Enumeration Date | 10/25/2018 |
| Last Update Date | 03/25/2019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1730656000 | NPI | - | NPPES |
| 1316219892 | Medicaid | IL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Secondary |
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