=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558923789
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLD OAK PSYCHOLOGICAL HEALTH CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2019
-----------------------------------------------------
Last Update Date | 10/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E PROSPECT AVE STE 218
-----------------------------------------------------
City | MT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-3396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-999-3888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E PROSPECT AVE STE 218
-----------------------------------------------------
City | MT PROSPECT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60056-3396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-999-3888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. JEREMY LUCE
-----------------------------------------------------
Credential | MA, PSYD
-----------------------------------------------------
Telephone | 847-999-3888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------