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General NPI Number Information
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NPI Number | 1568867398
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Entity Type | Organization
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Legal Business Name | ANDERSONVILLE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 10/22/2014
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Last Update Date | 10/22/2014
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Provider Practice Location Address
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Address Line | 5412 N CLARK ST SUITE 210
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City | CHICAGO
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State | IL
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Zip | 60640-1272
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Country | US
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Telephone | 847-331-4600
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Fax | 773-409-5590
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Provider Business Mailing Address
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Address Line | 5315 N CLARK ST STE 319
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City | CHICAGO
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State | IL
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Zip | 60640-2290
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Country | US
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Telephone | 847-331-4600
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Fax | 773-409-5590
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Authorized Official
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Title or Position | CHIEF PSYCHOLOGIST
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Name | DR. ROBERT T BAKER III
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Credential | PSY.D.
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Telephone | 847-331-4600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 071006239
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License Number State | IL
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