Healthcare Provider Details

I. General information

NPI: 1730468307
Provider Name (Legal Business Name): PSYCHIATRY SPECIALISTS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 N BEACON ST
CHICAGO IL
60640-5518
US

IV. Provider business mailing address

4535 N BEACON ST
CHICAGO IL
60640-5518
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-0716
  • Fax:
Mailing address:
  • Phone: 773-629-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: STACY CLOYD
Title or Position: SECRETARY
Credential:
Phone: 904-605-4986