MEDICARE: ASSOCIATED BEHAVIORAL REHABILITATION SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TP2701X	Group Psychotherapy Psychologist

General Provider Information

NPI Number	:	1316069578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASSOCIATED BEHAVIORAL REHABILITATION SERVICES

Provider Business Mailing Address
First Line	:	4835 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2719
Country	:	US
Telephone Number	:	773-777-7413
Fax Number	:	773-777-7416

Provider Business Practice Location Address
First Line	:	4835 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2719
Country	:	US
Telephone Number	:	773-777-7413
Fax Number	:	773-777-7416

Authorized Official
Title or Position	:	OWNER
Name	:	MR. FRED T WALTZER
Credential	:	LCSW
Telephone Number	:	773-777-7413

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/22/2020

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