Provider Demographics
NPI:1124787379
Name:RESILIENCE RISING, PLLC
Entity type:Organization
Organization Name:RESILIENCE RISING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:224-534-0331
Mailing Address - Street 1:4648 N LECLAIRE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3817
Mailing Address - Country:US
Mailing Address - Phone:224-534-0331
Mailing Address - Fax:
Practice Address - Street 1:3411 W DIVERSEY AVE OFC 14
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1245
Practice Address - Country:US
Practice Address - Phone:224-534-0331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.018572OtherLICENSE NUMBER