Provider Demographics
NPI:1609243492
Name:INNER MISSION LLC
Entity Type:Organization
Organization Name:INNER MISSION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HULTGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:630-800-5207
Mailing Address - Street 1:801 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2294
Mailing Address - Country:US
Mailing Address - Phone:630-800-5207
Mailing Address - Fax:630-820-0170
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2294
Practice Address - Country:US
Practice Address - Phone:630-800-5207
Practice Address - Fax:630-820-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty