Healthcare Provider Details

I. General information

NPI: 1831511690
Provider Name (Legal Business Name): THE CHICAGO INTEGRATIVE CENTER FOR PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NORTH SHORE DR SUITE 120
LAKE BLUFF IL
60044-2243
US

IV. Provider business mailing address

900 NORTH SHORE DR SUITE 120
LAKE BLUFF IL
60044-2243
US

V. Phone/Fax

Practice location:
  • Phone: 847-615-1698
  • Fax: 847-615-1697
Mailing address:
  • Phone: 847-615-1698
  • Fax: 847-615-1697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number36117225
License Number StateIL

VIII. Authorized Official

Name: MS. ERIN BRIGHT
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 847-770-1241