Provider Demographics
NPI:1760028542
Name:ENVISION THERAPY, PLLC
Entity Type:Organization
Organization Name:ENVISION THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OLDENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, NCC
Authorized Official - Phone:847-922-5031
Mailing Address - Street 1:234 W WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE BLUFF
Mailing Address - State:IL
Mailing Address - Zip Code:60044-2036
Mailing Address - Country:US
Mailing Address - Phone:847-922-5031
Mailing Address - Fax:847-234-1191
Practice Address - Street 1:900 NORTH SHORE DR STE 200
Practice Address - Street 2:
Practice Address - City:LAKE BLUFF
Practice Address - State:IL
Practice Address - Zip Code:60044-2225
Practice Address - Country:US
Practice Address - Phone:847-922-5031
Practice Address - Fax:847-234-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health