=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528691748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSFORMEDGE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2020
-----------------------------------------------------
Last Update Date | 04/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 W JACKSON BLVD STE 824
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60604-3487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-835-7988
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2193
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60065-2193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOSEPH CHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-835-7988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------