Healthcare Provider Details

I. General information

NPI: 1578665147
Provider Name (Legal Business Name): ASSOCIATED CLINICAL PSYCHOLOGISTS, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 N NORTHWEST HWY SUITE 311D
PARK RIDGE IL
60068-1444
US

IV. Provider business mailing address

1580 N NORTHWEST HWY SUITE 311D
PARK RIDGE IL
60068-1444
US

V. Phone/Fax

Practice location:
  • Phone: 847-824-1235
  • Fax: 847-824-2386
Mailing address:
  • Phone: 847-824-1235
  • Fax: 847-824-2386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: DR. ALAN R. GRAHAM
Title or Position: PRESIDENT
Credential: PH.D
Phone: 847-824-1235