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General NPI Number Information
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NPI Number | 1386097186
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Entity Type | Organization
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Legal Business Name | LOGAN SQUARE COUNSELING LLC
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Dates
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Enumeration Date | 07/15/2016
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Last Update Date | 08/15/2016
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Provider Practice Location Address
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Address Line | 2724 N KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60647-1514
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Country | US
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Telephone | 773-245-3725
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Fax | 773-453-7258
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Provider Business Mailing Address
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Address Line | 2724 N KEDZIE AVE
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City | CHICAGO
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State | IL
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Zip | 60647-1514
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Country | US
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Telephone | 773-245-3725
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Fax | 773-453-7258
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Authorized Official
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Title or Position | PRESIDENT, LICENSED PSYCHOLOGIST
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Name | DR. MARK THOMAS SCIARRINO
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Credential | PSYD
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Telephone | 773-245-3725
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008195
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License Number State | IL
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