Healthcare Provider Details

I. General information

NPI: 1508460700
Provider Name (Legal Business Name): INTEGRATIVE THERAPEUTIC SOLUTIONS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2020
Last Update Date: 11/28/2020
Certification Date: 11/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 W RENWICK RD STE 204
PLAINFIELD IL
60544-8733
US

IV. Provider business mailing address

24012 W RENWICK RD STE 204
PLAINFIELD IL
60544-8733
US

V. Phone/Fax

Practice location:
  • Phone: 815-676-4688
  • Fax: 815-676-4498
Mailing address:
  • Phone: 815-676-4688
  • Fax: 815-676-4498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. EMMANUEL GONZALEZ
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 815-676-4688