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General NPI Number Information
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NPI Number | 1609821164
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Entity Type | Organization
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Legal Business Name | TRISTATE WELLNESS MGT LLC
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Dates
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Enumeration Date | 05/23/2006
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Last Update Date | 01/08/2008
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Provider Practice Location Address
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Address Line | 2826 N TALMAN UNIT J
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City | CHICAGO
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State | IL
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Zip | 60618-7828
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Country | US
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Telephone | 708-646-5738
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Fax | 866-587-1485
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Provider Business Mailing Address
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Address Line | 2826 N TALMAN UNIT J
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City | CHICAGO
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State | IL
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Zip | 60618-7828
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Country | US
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Telephone | 708-646-5738
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Fax | 866-587-1485
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | PHILIP DOUGLAS THOMPSON
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Credential |
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Telephone | 708-646-5738
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 336-008797
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 036093462
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License Number State | IL
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