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General NPI Number Information
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NPI Number | 1144644261
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Entity Type | Organization
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Legal Business Name | THEODORE HARRIS, LCSW, LLC
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Dates
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Enumeration Date | 02/10/2014
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Last Update Date | 10/13/2016
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Provider Practice Location Address
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Address Line | 53 W JACKSON BLVD SUITE 404
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City | CHICAGO
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State | IL
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Zip | 60604-3606
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Country | US
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Telephone | 312-576-5760
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Fax |
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Provider Business Mailing Address
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Address Line | 927 ASBURY AVE
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City | EVANSTON
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State | IL
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Zip | 60202-1637
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Country | US
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Telephone | 773-680-1534
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Fax | 312-674-7515
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Authorized Official
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Title or Position | OWNER
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Name | THEODORE R HARRIS
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Credential | L.C.S.W.
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Telephone | 312-576-5760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149016113
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License Number State | IL
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