Healthcare Provider Details

I. General information

NPI: 1740795897
Provider Name (Legal Business Name): RUFUS GONZALES PSYCHOTHERPAY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2017
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6238 N CLARK ST
CHICAGO IL
60660-1202
US

IV. Provider business mailing address

6238 N CLARK ST
CHICAGO IL
60660-1202
US

V. Phone/Fax

Practice location:
  • Phone: 708-512-4854
  • Fax:
Mailing address:
  • Phone: 708-512-4854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071007450
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number071007450
License Number StateIL

VIII. Authorized Official

Name: DR. RUFUS R GONZALES
Title or Position: OWNER
Credential: PHD
Phone: 708-512-4854