Provider Demographics
NPI:1710490248
Name:WISEMIND CHICAGO, LLC
Entity Type:Organization
Organization Name:WISEMIND CHICAGO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:COHN
Authorized Official - Last Name:PACTANAC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-320-5168
Mailing Address - Street 1:5100 N RAVENSWOOD AVE STE 211
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-1710
Mailing Address - Country:US
Mailing Address - Phone:773-320-5168
Mailing Address - Fax:
Practice Address - Street 1:5100 N RAVENSWOOD AVE STE 211
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1710
Practice Address - Country:US
Practice Address - Phone:773-320-5168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490197611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1063794261OtherINDIVIDUAL NPI NUMBER