Healthcare Provider Details

I. General information

NPI: 1063789220
Provider Name (Legal Business Name): INTEGRATIVE PSYCHOLOGICAL HEALTHCARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N SHERIDAN RD APT. 9E
CHICAGO IL
60657-4954
US

IV. Provider business mailing address

3100 N SHERIDAN RD APT. 9E
CHICAGO IL
60657-4954
US

V. Phone/Fax

Practice location:
  • Phone: 877-571-5579
  • Fax:
Mailing address:
  • Phone: 877-571-5579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number071007352
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN CHRISTIAN HARDIE
Title or Position: CLINICAL DIRECTOR
Credential: PHD
Phone: 312-810-5646