=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275911141
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CYNTHIA LUBIN LANGTIW PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2015
-----------------------------------------------------
Last Update Date | 05/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 N WELLS ST #2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60654-7024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-988-5148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1416 N NOBLE ST #2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60642-2365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-988-5148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071007343
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 071007343
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number | 071007343
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | 071007343
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------