Healthcare Provider Details

I. General information

NPI: 1558008904
Provider Name (Legal Business Name): OWEN ENOCH MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E OGDEN AVE STE 220
HINSDALE IL
60521-3546
US

IV. Provider business mailing address

250 E PLYMOUTH ST
VILLA PARK IL
60181-1744
US

V. Phone/Fax

Practice location:
  • Phone: 630-653-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: