Provider Demographics
NPI:1306652540
Name:MIND OF CHRIST LIFE COUNSELING PLLC
Entity type:Organization
Organization Name:MIND OF CHRIST LIFE COUNSELING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:SIMONE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:904-452-6725
Mailing Address - Street 1:9200 S EMERALD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-2741
Mailing Address - Country:US
Mailing Address - Phone:904-452-6725
Mailing Address - Fax:
Practice Address - Street 1:9200 S EMERALD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-2741
Practice Address - Country:US
Practice Address - Phone:904-452-6725
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health