Provider Demographics
NPI:1811579030
Name:INNER EQUINOX COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:INNER EQUINOX COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KRC
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:224-338-6038
Mailing Address - Street 1:210 CRYSTAL ST STE C
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-2096
Mailing Address - Country:US
Mailing Address - Phone:224-338-6038
Mailing Address - Fax:
Practice Address - Street 1:210 CRYSTAL ST STE C
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:IL
Practice Address - Zip Code:60013-2096
Practice Address - Country:US
Practice Address - Phone:224-338-6038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-27
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400646798Medicaid