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General NPI Number Information
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NPI Number | 1013316470
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Entity Type | Organization
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Legal Business Name | FAMILY BUILDING BLOCKS
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 08/21/2014
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Provider Practice Location Address
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Address Line | 10450 S WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60643-2508
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Country | US
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Telephone | 773-429-9454
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Fax |
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Provider Business Mailing Address
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Address Line | 10450 S WESTERN AVE
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City | CHICAGO
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State | IL
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Zip | 60643-2508
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Country | US
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Telephone | 773-429-9454
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Fax |
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Authorized Official
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Title or Position | LCPC
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Name | MRS. TRACY BOUCK
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Credential | MA
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Telephone | 773-429-9454
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 1825273
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License Number State | IL
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