Provider Demographics
NPI:1538946819
Name:CHRYSALIS WELLNESS AND CONSULTING GROUP LLC
Entity type:Organization
Organization Name:CHRYSALIS WELLNESS AND CONSULTING GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-799-9810
Mailing Address - Street 1:159 N SANGAMON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2201
Mailing Address - Country:US
Mailing Address - Phone:312-799-9810
Mailing Address - Fax:312-500-0409
Practice Address - Street 1:159 N SANGAMON ST STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2201
Practice Address - Country:US
Practice Address - Phone:312-799-9810
Practice Address - Fax:312-500-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
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