Provider Demographics
NPI:1720341993
Name:NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING
Entity type:Organization
Organization Name:NORTHSIDE CENTER FOR RELATIONSHIP COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:SMITH
Authorized Official - Last Name:HETHERINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LCPC
Authorized Official - Phone:773-791-0469
Mailing Address - Street 1:1770 W BERTEAU AVE
Mailing Address - Street 2:SUITE 302A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1849
Mailing Address - Country:US
Mailing Address - Phone:773-791-0469
Mailing Address - Fax:
Practice Address - Street 1:1770 W BERTEAU AVE
Practice Address - Street 2:SUITE 302A
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1849
Practice Address - Country:US
Practice Address - Phone:773-791-0469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.003937101YM0800X
IL166.000557106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty