Provider Demographics
NPI:1063847622
Name:TRANSFORMATIVE PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:TRANSFORMATIVE PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RIVITZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-484-5186
Mailing Address - Street 1:950 W LELAND AVE
Mailing Address - Street 2:#310
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-7100
Mailing Address - Country:US
Mailing Address - Phone:773-484-5186
Mailing Address - Fax:
Practice Address - Street 1:4753 N BROADWAY ST
Practice Address - Street 2:830
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5266
Practice Address - Country:US
Practice Address - Phone:773-484-5186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-13
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490020371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty