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General NPI Number Information
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NPI Number | 1063883395
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Entity Type | Organization
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Legal Business Name | KB PSYCHOLOGICAL PRACTICE, PC
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Dates
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Enumeration Date | 10/13/2015
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Last Update Date | 08/25/2016
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Provider Practice Location Address
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Address Line | 7010 S UNION AVE
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City | CHICAGO
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State | IL
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Zip | 60621-2418
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Country | US
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Telephone | 708-925-4523
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Fax | 855-727-4855
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Provider Business Mailing Address
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Address Line | 1824 CAMBRIDGE AVE
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City | FLOSSMOOR
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State | IL
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Zip | 60422-2132
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Country | US
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Telephone | 708-925-4523
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Fax | 855-727-4855
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Authorized Official
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Title or Position | PRESIDENT / OWNER
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Name | DR. KIMBERLY L BAKER
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Credential | PSYD
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Telephone | 708-925-4523
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.00142
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License Number State | IL
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