=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477900199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE NEW CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 05/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3354 N PAULINA ST SUITE 204C
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-405-3541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3354 N PAULINA ST SUITE 204C
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KEVIN KUKOLECK
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 773-504-7341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------