Provider Demographics
NPI:1023731452
Name:INNER LENS THERAPY PLLC
Entity type:Organization
Organization Name:INNER LENS THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:224-733-9321
Mailing Address - Street 1:3300 W PALMER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-7437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 W PALMER ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-7437
Practice Address - Country:US
Practice Address - Phone:224-733-9321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)