Healthcare Provider Details

I. General information

NPI: 1295226736
Provider Name (Legal Business Name): SPRINGPSYCH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 529
CHICAGO IL
60602-3491
US

IV. Provider business mailing address

1441 W ELMDALE AVE APT 1S
CHICAGO IL
60660-2405
US

V. Phone/Fax

Practice location:
  • Phone: 312-629-5075
  • Fax:
Mailing address:
  • Phone: 239-248-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number071009689
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071009689
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT SCOTT WALLER
Title or Position: OWNER, CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 239-248-7437