Healthcare Provider Details

I. General information

NPI: 1225310865
Provider Name (Legal Business Name): INTERNATIONAL BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10448 S PULASKI RD SUITE 4
OAK LAWN IL
60453-4895
US

IV. Provider business mailing address

1550 E 61ST ST 1N
CHICAGO IL
60637-2973
US

V. Phone/Fax

Practice location:
  • Phone: 312-834-3697
  • Fax:
Mailing address:
  • Phone: 312-554-9934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20992
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number180007270
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMFT-125
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014748
License Number StateIL

VIII. Authorized Official

Name: CRYSTAL SMITH
Title or Position: DIRECTOR
Credential: IMFT, LCSW
Phone: 312-554-9934