Provider Demographics
NPI:1003396599
Name:OBSIDIAN COUNSELING AND WELLNESS, LLC
Entity Type:Organization
Organization Name:OBSIDIAN COUNSELING AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ILYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LASKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-208-2972
Mailing Address - Street 1:723 ELM ST STE 20
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:IL
Mailing Address - Zip Code:60093-2565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:723 ELM ST STE 20
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2565
Practice Address - Country:US
Practice Address - Phone:847-208-2972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health