Healthcare Provider Details

I. General information

NPI: 1184236002
Provider Name (Legal Business Name): FREELIFE BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5315 N CLARK ST # 215
CHICAGO IL
60640-2290
US

IV. Provider business mailing address

5315 N CLARK ST # 215
CHICAGO IL
60640-2290
US

V. Phone/Fax

Practice location:
  • Phone: 908-229-3578
  • Fax:
Mailing address:
  • Phone: 908-229-3578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. IAN BONNER
Title or Position: CEO
Credential: PSYD
Phone: 908-229-3578