Provider Demographics
NPI:1710799796
Name:290 THERAPY LLC
Entity type:Organization
Organization Name:290 THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-490-4853
Mailing Address - Street 1:18141 DIXIE HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2243
Mailing Address - Country:US
Mailing Address - Phone:309-490-4853
Mailing Address - Fax:
Practice Address - Street 1:811 GREENBAY AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-4424
Practice Address - Country:US
Practice Address - Phone:309-490-4853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)