Healthcare Provider Details

I. General information

NPI: 1295568772
Provider Name (Legal Business Name): WEST LOOP PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 W LAKE ST STE 2S
CHICAGO IL
60661-1034
US

IV. Provider business mailing address

661 W LAKE ST STE 2S
CHICAGO IL
60661-1034
US

V. Phone/Fax

Practice location:
  • Phone: 312-768-8215
  • Fax: 267-367-5929
Mailing address:
  • Phone: 312-768-8215
  • Fax: 267-367-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYDNEY STATHES
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: PMHNP
Phone: 312-768-8215