Healthcare Provider Details

I. General information

NPI: 1114882677
Provider Name (Legal Business Name): SPENCER RYBACKI
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 W BELMONT AVE STE 1
CHICAGO IL
60618-6796
US

IV. Provider business mailing address

1142 W MADISON ST STE 302
CHICAGO IL
60607-2191
US

V. Phone/Fax

Practice location:
  • Phone: 312-324-4502
  • Fax:
Mailing address:
  • Phone: 312-324-4502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number178.022607
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: