=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669915831
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EATING RECOVERY CENTER INSIGHT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2016
-----------------------------------------------------
Last Update Date | 11/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 LAKE COOK RD STE 303
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-378-7246
-----------------------------------------------------
Fax | 847-559-9428
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1535 LAKE COOK RD STE 303
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-378-7246
-----------------------------------------------------
Fax | 847-559-9428
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL MANAGER
-----------------------------------------------------
Name | JENNIFER L MCADAMS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 847-997-3910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.009963
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------