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General NPI Number Information
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NPI Number | 1487410007
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Entity Type | Organization
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Legal Business Name | ILLUMENTAL COUNSELING AND PSYCHIATRY, PLLC
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Dates
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Enumeration Date | 02/21/2024
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Last Update Date | 12/26/2024
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Provider Practice Location Address
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Address Line | 53 W JACKSON BLVD STE 1260
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City | CHICAGO
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State | IL
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Zip | 60604-3631
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Country | US
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Telephone | 312-456-0225
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Fax |
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Provider Business Mailing Address
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Address Line | 53 W JACKSON BLVD STE 1260
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City | CHICAGO
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State | IL
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Zip | 60604-3631
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Country | US
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Telephone | 312-456-0225
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ALEXANDER OBOLSKY
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Credential | MD
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Telephone | 312-608-4695
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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