=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063179901
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR PSYCHOLOGICAL WELL BEING AND EMPOWERMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2021
-----------------------------------------------------
Last Update Date | 11/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2858 W DIVERSEY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60647-1871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-374-6621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7649 W RASCHER AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60656-1736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-201-7742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | DR. AZADEH FATEMI
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 573-201-7742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------