Healthcare Provider Details

I. General information

NPI: 1154187433
Provider Name (Legal Business Name): INTEGRATIVE PRIMARY CARE AND MENTAL HEALTH CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S WALLACE ST
CHICAGO IL
60616-3501
US

IV. Provider business mailing address

3201 S WALLACE ST
CHICAGO IL
60616-3501
US

V. Phone/Fax

Practice location:
  • Phone: 312-975-8268
  • Fax:
Mailing address:
  • Phone: 312-975-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE CHAN
Title or Position: MANAGER
Credential: DNP, FNP-BC, PMHNP-B
Phone: 312-975-8268