Provider Demographics
NPI:1730579012
Name:CATHARTIC SPACE LTD
Entity type:Organization
Organization Name:CATHARTIC SPACE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:773-633-9075
Mailing Address - Street 1:3166 N LINCOLN AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3166 N LINCOLN AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3133
Practice Address - Country:US
Practice Address - Phone:773-633-9075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008355101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty