Provider Demographics
NPI:1174230585
Name:DISTINCTIVELY ME
Entity type:Organization
Organization Name:DISTINCTIVELY ME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOTSON-LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-504-1571
Mailing Address - Street 1:33 W 155TH PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 W 155TH PL
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1202
Practice Address - Country:US
Practice Address - Phone:708-730-2340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health