Healthcare Provider Details

I. General information

NPI: 1013409366
Provider Name (Legal Business Name): CRAWFORD AVENUE GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 06/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 CRAWFORD AVE STE 206
EVANSTON IL
60201-4959
US

IV. Provider business mailing address

2530 CRAWFORD AVE STE 206
EVANSTON IL
60201-4959
US

V. Phone/Fax

Practice location:
  • Phone: 847-875-4411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007124
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149003065
License Number StateIL

VIII. Authorized Official

Name: KELLI KLINGER
Title or Position: PRESIDENT
Credential:
Phone: 847-875-4411