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General NPI Number Information
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NPI Number | 1457796385
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Entity Type | Organization
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Legal Business Name | PRIVATE PRACTICE
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Dates
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Enumeration Date | 05/06/2013
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Last Update Date | 05/06/2013
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Provider Practice Location Address
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Address Line | 76 E 89TH PL
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City | CHICAGO
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State | IL
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Zip | 60619-6607
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Country | US
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Telephone | 773-383-4149
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Fax |
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Provider Business Mailing Address
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Address Line | 76 E 89TH PL
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City | CHICAGO
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State | IL
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Zip | 60619-6607
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Country | US
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Telephone | 773-383-4149
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF MENTAL HEALTH
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Name | MRS. MAMIE ROBINSON
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Credential |
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Telephone | 773-383-4149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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