Healthcare Provider Details

I. General information

NPI: 1558536094
Provider Name (Legal Business Name): PARK RIDGE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S. NORTHWEST HIGHWAY SUITE 300
PARK RIDGE IL
60068
US

IV. Provider business mailing address

350 S. NORTHWEST HIGHWAY SUITE 300
PARK RIDGE IL
60068
US

V. Phone/Fax

Practice location:
  • Phone: 847-722-5967
  • Fax:
Mailing address:
  • Phone: 847-722-5967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071007131
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number071.007131
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number071.007131
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number071.007131
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number071.007131
License Number StateIL

VIII. Authorized Official

Name: DR. TARA GIDNEY THOMPSON
Title or Position: PARTNER/OWNER
Credential: PSYD
Phone: 847-722-5967