Provider Demographics
NPI:1619453610
Name:HEAD HEART THERAPY
Entity Type:Organization
Organization Name:HEAD HEART THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-591-4311
Mailing Address - Street 1:3759 N RAVENSWOOD AVE STE 133
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3997
Mailing Address - Country:US
Mailing Address - Phone:773-892-1933
Mailing Address - Fax:
Practice Address - Street 1:4809 N RAVENSWOOD AVE UNIT 227
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4417
Practice Address - Country:US
Practice Address - Phone:773-892-1933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEAD HEART THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-8942-0002-A261QR0405X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility