Provider Demographics
NPI:1356108260
Name:SELF THEORY LLC
Entity type:Organization
Organization Name:SELF THEORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-569-0791
Mailing Address - Street 1:770 N HALSTED ST STE 306
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-8407
Mailing Address - Country:US
Mailing Address - Phone:312-973-8687
Mailing Address - Fax:
Practice Address - Street 1:770 N HALSTED ST STE 306
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-8407
Practice Address - Country:US
Practice Address - Phone:312-973-8687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2025-01-16
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
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child