Provider Demographics
NPI:1750040341
Name:ORIGEM PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:ORIGEM PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAMILA
Authorized Official - Middle Name:O
Authorized Official - Last Name:DE AZEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:312-219-2476
Mailing Address - Street 1:1300 W BELMONT AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3200
Mailing Address - Country:US
Mailing Address - Phone:312-219-2476
Mailing Address - Fax:
Practice Address - Street 1:1300 W BELMONT AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3200
Practice Address - Country:US
Practice Address - Phone:312-219-2476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-11
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty