=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235521303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE PSYCHOLOGICAL SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2015
-----------------------------------------------------
Last Update Date | 06/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 S MILWAUKEE AVE STE 180
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-3200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-804-4360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4301 EXETER LN
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-804-4360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. KARINA BORTNIK
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 312-804-4360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 071006751
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------