Healthcare Provider Details

I. General information

NPI: 1366013054
Provider Name (Legal Business Name): INTERCULTURAL BEHAVIORAL HEALTH & CONSULTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2021
Last Update Date: 07/05/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N MICHIGAN AVE STE 569
CHICAGO IL
60601-7799
US

IV. Provider business mailing address

155 N MICHIGAN AVE STE 569
CHICAGO IL
60601-7799
US

V. Phone/Fax

Practice location:
  • Phone: 312-545-8480
  • Fax:
Mailing address:
  • Phone: 312-545-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: AYAKO KONNO
Title or Position: OWNER/PSYCHOLOGIST
Credential: PSYD
Phone: 312-545-8480