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General NPI Number Information
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NPI Number | 1134458466
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Entity Type | Organization
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Legal Business Name | POWER TEEN PROGRAM
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Dates
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Enumeration Date | 12/16/2009
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Last Update Date | 12/16/2009
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Provider Practice Location Address
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Address Line | 300 N CENTRAL AVE
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City | CHICAGO
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State | IL
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Zip | 60644
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Country | US
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Telephone | 312-261-1421
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Fax |
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Provider Business Mailing Address
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Address Line | 9336 MORGAN AVE
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City | EVANSTON
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State | IL
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Zip | 60203-1418
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Country | US
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Telephone | 312-261-1421
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MS. GLENDA CUNNINGHAM
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Credential |
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Telephone | 312-521-3336
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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 | 071002911
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License Number State | IL
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