Healthcare Provider Details

I. General information

NPI: 1710162862
Provider Name (Legal Business Name): WISE BEHAVIORAL HEALTH SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9012 S CRANDON AVE
CHICAGO IL
60617-3807
US

IV. Provider business mailing address

9012 S CRANDON AVE
CHICAGO IL
60617-3807
US

V. Phone/Fax

Practice location:
  • Phone: 773-375-8741
  • Fax: 773-375-8748
Mailing address:
  • Phone: 773-375-8741
  • Fax: 773-375-8748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. CHARLES TRIPP
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-510-6165