Provider Demographics
NPI:1699478990
Name:MY ART THERAPY STUDIO, PLLC
Entity type:Organization
Organization Name:MY ART THERAPY STUDIO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAQUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, ATR-BC
Authorized Official - Phone:502-554-4666
Mailing Address - Street 1:4610 N CLARK ST # 1203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-4620
Mailing Address - Country:US
Mailing Address - Phone:312-278-7628
Mailing Address - Fax:
Practice Address - Street 1:3124 W LOGAN BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-1627
Practice Address - Country:US
Practice Address - Phone:312-278-7628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-24
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty