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General NPI Number Information
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NPI Number | 1679832216
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGICAL SERVICES OF CHICAGO LTD
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Dates
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Enumeration Date | 05/15/2012
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Last Update Date | 11/19/2012
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Provider Practice Location Address
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Address Line | 1300 W BELMONT AVE SUITE 304
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City | CHICAGO
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State | IL
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Zip | 60657-3200
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Country | US
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Telephone | 312-909-6766
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Fax | 773-227-4773
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Provider Business Mailing Address
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Address Line | 1300 W BELMONT AVE SUITE 304
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City | CHICAGO
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State | IL
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Zip | 60657-3200
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Country | US
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Telephone | 312-909-6766
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Fax | 773-227-4773
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST/OWNER
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Name | CHRISTINA BAUTISTA
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Credential | PSY.D.
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Telephone | 312-909-6766
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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 | 071007551
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License Number State | IL
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