=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528525383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATERBROOK THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2019
-----------------------------------------------------
Last Update Date | 02/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10540 S WESTERN AVE STE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-559-5958
-----------------------------------------------------
Fax | 773-442-0085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10540 S WESTERN AVE STE 406
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60643-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-559-5958
-----------------------------------------------------
Fax | 773-442-0085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROBERT PRESTON STANFORD
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 312-725-0646
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------