Healthcare Provider Details

I. General information

NPI: 1134301815
Provider Name (Legal Business Name): SELF EMPOWERMENT CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 S NAPERVILLE RD SUITE 207
WHEATON IL
60189-5896
US

IV. Provider business mailing address

1751 S NAPERVILLE RD SUITE 207
WHEATON IL
60189-5896
US

V. Phone/Fax

Practice location:
  • Phone: 630-774-8316
  • Fax: 630-690-3353
Mailing address:
  • Phone: 630-774-8316
  • Fax: 630-690-3353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071-005466
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number071-005466
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number071-005733
License Number StateIL

VIII. Authorized Official

Name: DR. ASIF A KHAN
Title or Position: PRESIDENT
Credential: PSY.D
Phone: 630-774-8316