=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588069306
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED PSYCHIATRY OF ELGIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2014
-----------------------------------------------------
Last Update Date | 10/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2130 POINT BLVD SUITE 200
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-783-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2130 POINT BLVD SUITE 200
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60123-9215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-783-0307
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ALEATHA HOWEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-783-0307
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149004898
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149016112
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 036111811
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------