Provider Demographics
NPI:1780185280
Name:RESTORE PSYCHOTHERAPY AND YOGA
Entity Type:Organization
Organization Name:RESTORE PSYCHOTHERAPY AND YOGA
Other - Org Name:STEPHANIE MAZZANTI
Other - Org Type:Other Name
Authorized Official - Title/Position:PSYCHOTHERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZZANTI
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, E-RYT
Authorized Official - Phone:312-608-0097
Mailing Address - Street 1:4123 MEACHEM RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53403-3912
Mailing Address - Country:US
Mailing Address - Phone:312-608-0097
Mailing Address - Fax:
Practice Address - Street 1:3131 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:WI
Practice Address - Zip Code:53405-4524
Practice Address - Country:US
Practice Address - Phone:312-608-0097
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180009102261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)