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General NPI Number Information
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NPI Number | 1073804720
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Entity Type | Organization
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Legal Business Name | REALITY TALK, INC
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Dates
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Enumeration Date | 04/28/2011
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 1808 S STATE ST
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City | CHICAGO
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State | IL
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Zip | 60616-1611
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Country | US
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Telephone | 312-949-1340
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Fax | 312-949-1348
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Provider Business Mailing Address
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Address Line | 1507 E 53RD ST #275
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City | CHICAGO
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State | IL
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Zip | 60615-4573
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Country | US
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Telephone | 630-328-3571
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DIANE WASHINGTON
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Credential | M.D.
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Telephone | 630-328-3571
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 036-085290
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 036-085290
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License Number State | IL
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