=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659974053
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EQUAL MENTAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2020
-----------------------------------------------------
Last Update Date | 11/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3306 N HALSTED ST STE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-2974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-558-8478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3306 N HALSTED ST STE 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60657-2974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-558-8478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | DR. JUAN E ROMERO GADDI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 773-558-8478
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------