Provider Demographics
NPI:1104439413
Name:MIVA PSYCHOTHERAPY
Entity type:Organization
Organization Name:MIVA PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AYAOVI
Authorized Official - Middle Name:ESENAM
Authorized Official - Last Name:AMEZOTCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-674-2405
Mailing Address - Street 1:590 E THORNDALE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-3205
Mailing Address - Country:US
Mailing Address - Phone:630-674-2405
Mailing Address - Fax:
Practice Address - Street 1:475 DUNHAM RD STE 1E
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1498
Practice Address - Country:US
Practice Address - Phone:331-276-2355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty