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General NPI Number Information
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NPI Number | 1386705572
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Entity Type | Individual
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Provider Name | CORE BEHAVIORAL HEALTH, INC.
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Gender | Male
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Dates
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Enumeration Date | 12/12/2006
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Last Update Date | 04/24/2009
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Provider Practice Location Address
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Address Line | 1300 W. Belmont Avenue Suite # 504
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City | Chicago
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State | IL
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Zip | 60657
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Country | US
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Telephone | 800-994-6602 x 101
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Fax | 800-994-6602
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Provider Business Mailing Address
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Address Line | 9217 W. Montgomery Drive
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City | Orland Park
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State | IL
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Zip | 60462
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Country | US
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Telephone | 8009946602 x 101
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Fax | 888-994-6602
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 071.007541
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License Number State | IL
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