Healthcare Provider Details

I. General information

NPI: 1932578234
Provider Name (Legal Business Name): KHALIL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N MAIN ST SUITE 103
GLEN ELLYN IL
60137-3581
US

IV. Provider business mailing address

999 N MAIN ST SUITE 103
GLEN ELLYN IL
60137-3581
US

V. Phone/Fax

Practice location:
  • Phone: 630-474-4414
  • Fax: 630-230-3364
Mailing address:
  • Phone: 630-474-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.010934
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.008541
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180009783
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036093319
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007457
License Number StateIL

VIII. Authorized Official

Name: HOOMAN KESHAVARZI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 224-622-3116