Provider Demographics
NPI:1356064208
Name:SELF ASSEMBLED PSYCHOTHERAPY, PLLC
Entity type:Organization
Organization Name:SELF ASSEMBLED PSYCHOTHERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & BILINGUAL PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:JELLINEK
Authorized Official - Last Name:ALDAG
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, NCC
Authorized Official - Phone:608-217-4711
Mailing Address - Street 1:5206 N LIND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1436
Mailing Address - Country:US
Mailing Address - Phone:608-217-4711
Mailing Address - Fax:
Practice Address - Street 1:5206 N LIND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1436
Practice Address - Country:US
Practice Address - Phone:608-217-4711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1760098966OtherLICENSED PROFESSIONAL COUNSELOR