=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336237437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR BEHAVIORAL MEDICINE LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 N MICHIGAN AVE SUITE 2800
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-245-3120
-----------------------------------------------------
Fax | 312-245-3124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 N MICHIGAN AVE SUITE 2800
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-4066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-245-3120
-----------------------------------------------------
Fax | 312-245-3124
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DR. DANIEL S. KIRSCHENBAUM
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 312-245-3120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 072-003557
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------