Healthcare Provider Details

I. General information

NPI: 1760436398
Provider Name (Legal Business Name): ASSOCIATED BEHAVIORAL CONSULTANTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4835 W IRVING PARK RD
CHICAGO IL
60641-2719
US

IV. Provider business mailing address

4835 W IRVING PARK RD
CHICAGO IL
60641-2719
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-7413
  • Fax:
Mailing address:
  • Phone: 773-777-7413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number149001505
License Number StateIL

VIII. Authorized Official

Name: FRED T WALTZER
Title or Position: PRESIDENT
Credential: LCSW
Phone: 773-777-7413