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General NPI Number Information
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NPI Number | 1194136051
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Entity Type | Organization
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Legal Business Name | BLUE LOTUS PSYCHOLOGICAL SERVICES, INC.
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 05/14/2014
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Provider Practice Location Address
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Address Line | 1525 E 53RD ST STE. 405
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City | CHICAGO
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State | IL
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Zip | 60615-4557
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Country | US
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Telephone | 773-551-3916
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Fax |
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Provider Business Mailing Address
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Address Line | 1525 E 53RD ST STE. 405
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City | CHICAGO
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State | IL
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Zip | 60615-4557
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PSYCHOLOGIST
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Name | DR. ANNE-MARIE NICOLAS
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Credential | PSY.D.
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Telephone | 773-551-3916
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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 | 071.008505
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License Number State | IL
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