=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235234733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE COUNSELING & PSYCHOLOGICAL SERVICES,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3925 75TH ST SUITE105
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-7913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-701-1117
-----------------------------------------------------
Fax | 630-983-1914
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3925 75TH ST SUITE105
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60504-7913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-701-1117
-----------------------------------------------------
Fax | 630-983-1914
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MICHELE C DERENGOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-920-4076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------