Provider Demographics
NPI:1861074254
Name:GROUNDED HEALING LLC
Entity type:Organization
Organization Name:GROUNDED HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-420-4316
Mailing Address - Street 1:1516 W 18TH PL # 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2802
Mailing Address - Country:US
Mailing Address - Phone:312-420-4316
Mailing Address - Fax:
Practice Address - Street 1:1516 W 18TH PL # 1R
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2802
Practice Address - Country:US
Practice Address - Phone:312-420-4316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)