Healthcare Provider Details

I. General information

NPI: 1821540428
Provider Name (Legal Business Name): CHICAGO BEHAVIORAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2016
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 N CLARK ST STE 206
CHICAGO IL
60614-1850
US

IV. Provider business mailing address

2502 N CLARK ST STE 206
CHICAGO IL
60614-1850
US

V. Phone/Fax

Practice location:
  • Phone: 773-850-0294
  • Fax:
Mailing address:
  • Phone: 773-850-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008535
License Number StateIL

VIII. Authorized Official

Name: DR. AZADEH GHAFFARI
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 773-850-0294