Provider Demographics
NPI:1023651049
Name:URBANSTREETZ THERAPY LLC
Entity type:Organization
Organization Name:URBANSTREETZ THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-703-8486
Mailing Address - Street 1:8364 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-6437
Mailing Address - Country:US
Mailing Address - Phone:773-703-8486
Mailing Address - Fax:
Practice Address - Street 1:9204 S COMMERCIAL AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2197
Practice Address - Country:US
Practice Address - Phone:773-703-8486
Practice Address - Fax:773-530-7588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-22
Last Update Date:2022-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1508393562Medicaid