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General NPI Number Information
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NPI Number | 1356946008
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Entity Type | Organization
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Legal Business Name | RESTORE CHANGE LLC
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Dates
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Enumeration Date | 12/01/2020
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Last Update Date | 12/01/2020
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Provider Practice Location Address
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Address Line | 1011 E WILSON AVE
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City | LOMBARD
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State | IL
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Zip | 60148-3765
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Country | US
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Telephone | 630-708-0120
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Fax |
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Provider Business Mailing Address
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Address Line | 1011 E WILSON AVE
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City | LOMBARD
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State | IL
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Zip | 60148-3765
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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 | EXECUTIVE DIRECTOR
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Name | DR. FAHAD KHAN
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Credential | PSYD
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Telephone | 630-708-0120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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