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General NPI Number Information
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NPI Number | 1417852971
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Entity Type | Organization
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Legal Business Name | ASSEMBLAGE PSYCHOLOGICAL SERVICES, PLLC
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Dates
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Enumeration Date | 10/13/2026
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Last Update Date | 10/13/2026
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Provider Practice Location Address
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Address Line | 3323 W DIVERSEY AVE
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City | CHICAGO
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State | IL
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Zip | 60647-8582
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Country | US
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Telephone | 312-248-3442
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Fax |
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Provider Business Mailing Address
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Address Line | 7230 OLCOTT AVE
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City | HAMMOND
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State | IN
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Zip | 46323-2044
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Country | US
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Telephone | 312-248-3442
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LESLIE K POULOS
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Credential | PSYD
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Telephone | 312-248-3442
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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 |
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License Number State |
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