Healthcare Provider Details

I. General information

NPI: 1558008904
Provider Name (Legal Business Name): OWEN ENOCH MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E LAKE ST STE 1300
CHICAGO IL
60601-7458
US

IV. Provider business mailing address

70 E LAKE ST STE 1300
CHICAGO IL
60601-7458
US

V. Phone/Fax

Practice location:
  • Phone: 312-726-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071.022799
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: