=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023580123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOWNEY THERAPEUTIC SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2018
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 E WACKER DR UNIT 207
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-498-9700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 E WACKER DR UNIT 207
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-5282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-498-9700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEISHA DOWNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-498-9700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------