Healthcare Provider Details

I. General information

NPI: 1033626932
Provider Name (Legal Business Name): HOPE BEHAVIOR PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N LARKIN AVE
JOLIET IL
60435-3441
US

IV. Provider business mailing address

215 BROOKWOOD LN E
BOLINGBROOK IL
60440-5517
US

V. Phone/Fax

Practice location:
  • Phone: 630-863-0408
  • Fax:
Mailing address:
  • Phone: 630-863-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.019648
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. AUDREY R DAVIS
Title or Position: PSYCHOTHERAPIST/CLINICAL SW
Credential: MSW, LCSW
Phone: 630-863-0408