MEDICARE: PSYCHOTHERAPY ASSOCIATES OF CHICAGO

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	1041C0700X	Clinical Social Worker	149009584	IL

General Provider Information

NPI Number	:	1568518520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOTHERAPY ASSOCIATES OF CHICAGO

Provider Business Mailing Address
First Line	:	1954 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2408
Country	:	US
Telephone Number	:	773-414-4577
Fax Number	:	773-313-3533

Provider Business Practice Location Address
First Line	:	1954 W IRVING PARK RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-2408
Country	:	US
Telephone Number	:	773-414-4577
Fax Number	:	773-313-3533

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MICHAEL JON VERNON
Credential	:	LCSW
Telephone Number	:	773-414-4577

Provider Enumeration Date	:	01/25/2007
Last Update Date	:	03/17/2018

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Directions to “PSYCHOTHERAPY ASSOCIATES OF CHICAGO ” Practice Location

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