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General NPI Number Information
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NPI Number | 1124521430
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Entity Type | Organization
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Legal Business Name | AMY BAZELON LCPC, LLC
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 10/28/2021
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Provider Practice Location Address
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Address Line | 839 MOSELEY RD
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-4635
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Country | US
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Telephone | 847-707-5424
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Fax |
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Provider Business Mailing Address
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Address Line | 839 MOSELEY RD
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City | HIGHLAND PARK
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State | IL
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Zip | 60035-4635
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Country | US
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Telephone | 847-432-8968
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | AMY BAZELON
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Credential | LCPC
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Telephone | 847-707-5424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 180.010546
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License Number State | IL
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