Provider Demographics
NPI:1558189076
Name:LAVENDER MOON SELF ILLUMINATING COUNSELING SERVICES PLLC
Entity type:Organization
Organization Name:LAVENDER MOON SELF ILLUMINATING COUNSELING SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCPC
Authorized Official - Prefix:
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-504-2528
Mailing Address - Street 1:11430 LAKEBROOK CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W RANDOLPH ST UNIT 1002
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1433
Practice Address - Country:US
Practice Address - Phone:708-918-4456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health